Texas Medicaid reimburses contracted pharmacy providers according to the “Pharmacy (Non-DME)” fee schedule. The estimated acquisition cost is defined in the Texas Administrative Code Title 1 §355.8541 relating to Legend and Non-legend Medication and §355.8545 relating to Texas Maximum Allowable Cost. To learn more about reimbursement refer to the Drug Pricing & Reimbursement (PDF) chapter of the Texas Medicaid Pharmacy Provider Procedure Manual.
Weekly Payment Cycle
The weekly payment cycle for all payable fee-for-service claims begins at 12:00 a.m. on Friday and ends at 11:59 p.m. the following Thursday. Payment is generally issued to providers’ financial institutions by Monday night and posted to providers accounts according to their financial institution's schedule (usually within 72 hours). Providers should take into account any federal or state holidays.
Accessing Payment Files
VDP payment registers and ASC X12N 835/5010 Health Care Payment/Advice statements are available online through the Payment File Portal (PFP). Pharmacy staff must complete and return the Electronic Remittance Advice Authorization Agreement (PDF) to register for access. Separate remittance advice and direct deposits will be made for each program area (Medicaid, CSHCN, and KHC).
There will be one-day payment delays because of the following federal bank holidays. This delay will affect claims paid by traditional Medicaid (fee-for-service), the Kidney Health Care (KHC) Program, and the Children with Special Health Care Needs (CSHCN) Services Program.
- New Year's (Monday, January 2, 2017)
- Claims submitted December 23 through 29, 2016 will have a payment date of January 3, with deposits available January 5.
- Martin Luther King, Jr. Day (Monday, January 16, 2017)
- Claims submitted January 6 through 12 will have a payment date of January 17, with deposits available January 19.
- Presidents' Day (Monday, February 20, 2017)
- Claims submitted February 10-16 through will have a payment date of February 21, with deposits available February 23.
- Memorial Day (Monday, May 29, 2017)
- Claims submitted May 19 through 25 will have a payment date of May 30, with deposits available June 1.
- Labor Day (Monday, September 4, 2017)
- Claims submitted August 25 through 31 will have a payment date of September 5, with deposits available September 7.
- Columbus Day (Monday, October 9, 2017)
- Claims submitted September 29 through October 5 will have a payment date of October 10, with deposits available October 12.
- Christmas Day (Monday, December 25, 2017)
- Claims submitted December 15 through 21 will have a payment date of December 26, with deposits available December 28.
Pharmacy providers that want to receive their weekly payment by direct deposit must complete the Direct Deposit Authorization (form 74-176). This form is also used to change bank information, such as financial institution, account number, or cancellation of account. An account change will result in the pharmacy provider receiving paper warrants until the process is completed. Completed forms should be sent to the Medicaid/CHIP Contract Compliance.
Claims billed incorrectly, resulting in the pharmacy provider owing the Vendor Drug Program a refund, should be adjusted or recouped within 90 days of the original date of service. If it is necessary to issue a refund the pharmacy provider should refer to the instructions as noted in Section 8.5 (Pharmacy Refunds) of the Texas Pharmacy Provider Procedure Manual.