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, Section 355.8541 relating to Legend and Non-legend Medication. To learn more about reimbursement refer to the Drug Pricing and Reimbursement (PDF) chapter of the Texas Medicaid Pharmacy Provider Procedure Manual.
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.
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 (HHS Form 1316) to register for PFP access.
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.
Pharmacy providers that want to receive their weekly payment by direct deposit must complete the Direct Deposit Authorization (CPA 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 Texas HHS.
Claims billed incorrectly, resulting in the pharmacy 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 then the pharmacy should refer to the instructions in the Payment (PDF) chapter of the Texas Medicaid Pharmacy Provider Procedure Manual.