Pharmacy Benefit Information
Select vitamin and mineral products are classified as a Title XIX (Medicaid) home health benefit as durable medical equipment or medical supplies. These products are available to people 20 years of age and younger enrolled in Medicaid, the Children’s Health Insurance Program (CHIP), and the Children with Special Health Care Needs (CSHCN) Services Program.
Pharmacies are not required to enroll as a durable medical equipment (DME) provider or in the Medicaid Comprehensive Care Program (CCP) to provide access to the vitamin and mineral products on the VDP formularies for Medicaid, CHIP, and CSHCN. Pharmacies that have already enrolled as a Medicaid DME or CCP provider have the choice to submit claims for vitamin and mineral products to either (but not both) the Texas Medicaid Healthcare Partnership (TMHP) as a medical benefit or pharmacy benefit. Please refer to the Vitamin and Mineral Products (PDF) chapter of the Pharmacy Provider Procedure Manual (PPPM) to learn more.
- Claims for traditional Medicaid (fee-for-service) and the CSHCN Services Program are submitted to VDP. Pharmacy staff should refer to the Pharmacy Benefit Chart in the PPPM for covered products, quantity guidelines, refill limitations, and reimbursement rates.
- Claims for Medicaid managed care and CHIP are submitted to the managed care organization (MCO). Pharmacy staff must work with the MCO's pharmacy benefit manager to determine the billing requirements, reimbursement rates, and coverage limitations for these products.
Comprehensive Care Program Benefit Information
Certain vitamin and mineral products prescribed or ordered by a physician to treat various conditions will be a benefit of Texas Medicaid through the Texas Medicaid Comprehensive Care Program (CCP) for people who are 20 years of age and younger. Such products will be billed to TMHP, manually priced, and will be a benefit when they are prior authorized and submitted with the corresponding procedure code and state-identified modifier.