MCOs are responsible for providing certain drugs on a non-risk cost-settlement basis in accordance with Section 10.18 of the Uniform Managed Care Contract (“Non-Risk Payments for Drugs”). Reimbursement by HHSC may be up to the Medicaid fee-for-service rate HHSC would have paid for the drug on the date of service for a valid claim. The non-risk payments will cover only the cost of the drugs. Reasonable administrative costs associated with coverage of these drugs, as well as any adjunctive therapies associated with the treatment of these drugs, are part of the existing capitation rate. The MCO may not include the cost of the drugs in the financial statistical report.

Drug list

Name Effective Date
Spinraza July 1, 2017
Exondys 51 Sept. 1, 2017
Kymriah Oct. 27, 2017
Besponsa Jan. 1, 2018
Brineura Jan. 1, 2018
Yescarta April 1, 2018
Luxturna July 1, 2018
Crysvita Nov. 1, 2018
Zolgensma July, 1, 2019