Spring 2015 - Texas Medicaid/CHIP Vendor Drug Program

► Managed Care Expansions in March
Two new Medicaid Managed Care initiatives will begin on March
1, including the addition of nursing facility services to
STAR+PLUS and the Texas Dual Eligible Integrated Care
Texas Health & Human Services Commission
Medicaid/CHIP Division Vendor Drug Program
Spring 2015
Vol. XXV ● Issue I
► Ingredient Cost & Dispensing Fee Changes
Slated For Summer
Last year the Vendor Drug Program contracted with Myers and Stauffer to
conduct surveys of retail community pharmacies to perform an evaluation
of the actual acquisition cost and perform a cost of dispensing study. Their
results were published in August. Based on the stakeholder input received,
VDP proposed a higher average dispensing fee based on the mean
weighted by Medicaid volume. HHSC chose to implement a differentiated
reimbursement methodology with ingredient costs that differ by pharmacy
type and a dispensing fee formula with a variable component. The new
Ingredient Cost methodology will utilize Wholesale Acquisition Cost
(WAC) or National Average Drug Acquisition Cost (NADAC), the new
benchmark of retail pharmacy acquisition costs developed by the Centers
for Medicare & Medicaid Services (CMS). The new rates will be:
Ingredient Cost
o NADAC (or WAC minus 2 percent) for retail pharmacies
and lower rates for specialty and long term care (LTC)
Dispensing Fee
o $7.93 + (1.96 percent of the ingredient cost) per claim.
The new pricing methodology is scheduled for later this summer. This
change only affects claims processed by VDP, including fee-for-service
Medicaid, the Children with Special Health Care Needs (CSHCN) Services
Program, the Kidney Health Care (KHC) program, and the Texas Women’s
Health Program. These changes are not related to and do not impact
managed care organization reimbursement rates. ■
► 340B Reimbursement Changes Now in Effect
On February 1, VDP changed the reimbursement methodology for
calculating the ingredient cost of outpatient pharmacy claims processed by
VDP and paid to eligible health care organizations participating in the
Health Resources and Services Administration (HRSA) 340B Drug Pricing
Program. The new methodology is as follows:
Human Immunodeficiency Virus (HIV) products
o WAC minus 43 percent
Hemophilia products
o WAC minus 35 percent
Brands and generics
o WAC minus 60 percent
The new 340B reimbursement methodology is not all-inclusive and some
products may be priced manually. Pharmacies participating in the 340B
Program can review VDP's pricing and rebate procedures in the VDP
Pharmacy Provider Procedure Manual, available online at
TxVendorDrug.com/downloads/. ■
► VDP Field Offices Closing
All Vendor Drug Program regional offices will close March 6, 2015. VDP
no longer requests prescription documentation for monthly review. Please
contact your assigned regional office in Fort Worth, Houston, McAllen,
Midland, or San Antonio if there are outstanding issues or questions. After
March 6, pharmacy providers should contact VDP Pharmacy Benefit
Access at 1-800-435-4165. ■
Nursing Home Expansion
STAR+PLUS managed care organizations will begin paying
providers for most Medicaid nursing facility services for
Medicaid recipients ages 21 and older. Medicaid members in
nursing facilities will be transitioning to one of the following
STAR+PLUS health plans: Amerigroup, Cigna-HealthSpring,
Molina Healthcare, Superior Health Plan, or United Healthcare.
To learn more visit
Dual Eligible Integrated Care Project
The goal of this project is to better coordinate the care that people
receive who are eligible for both Medicare and Medicaid, known
as dual eligibles. The plan involves a three-party agreement
between a Medicare-Medicaid health plan, the state of Texas, and
the federal Centers for Medicare and Medicaid Services (CMS) to
provide the person with the full array of Medicaid and Medicare
services. Members will be in the project if they meet all criteria:
• Are age 21 or older;
• Receive Medicare Part A, B and D, and receive full
Medicaid benefits;
• Enrolled in the Medicaid STAR+PLUS program.
Participating counties in the demonstration include Bexar, Dallas,
El Paso, Harris, Hidalgo, and Tarrant. To learn more visit
Schedules for statewide Medicaid Managed Care initiatives
provider trainings are available at the HHSC Meetings and Events
page at hhsc.state.tx.us/news/meetings.asp. VDP provides a
number of online resources for the pharmacy community to assist
with health plan claim processing and prior authorization at
The Pharmacy Enrollment Chart identifies how pharmacy
providers with questions pertaining to a new, pending, or
existing contract can contact each health plan and pharmacy
benefits manager (PBM).
The Pharmacy Assistance Chart identifies the name and
pharmacy billing information for each health plan and
individual call center phone numbers.
The Prescriber Assistance Chart identifies prior
authorization and member call center phone numbers for
each health plan. ■
► Hepatitis C Virus Authorizations
On January 23, VDP began allowing restricted Hepatitis C Virus
(HCV) treatment approval for qualifying patients via prior
authorization. The clinical edit applies to eligible clients enrolled
in either fee-for-service Medicaid or managed care. The only
Hep C treatment regimens available at this time include:
• Sovaldi 400mg tablet (61958150101)
• Olysio 150mg capsule (59676022528)
The entire HCV drug class was reviewed at the January Texas
Pharmaceutical and Therapeutics Committee meeting, and VDP
will implement newly approved Hepatitis C treatments later this
year. ■
►Links To Health Plan’s Clinical Edit Criteria
Certain clinical prior authorization edits must be performed for Medicaid
Managed Care clients. Health plans may implement any other of the Vendor
Drug Program’s edits but no more. Each health plan's pharmacy website must
include a list of that plan's implemented clinical edits for covered drugs. A link
TxVendorDrug.com/dur/clinical-edit-criteria.shtml to assist pharmacies in
identifying which edits apply to which health plan. ■
Medicaid/CHIP Vendor Drug Program (MC-2250)
Texas Health and Human Services Commission
4900 North Lamar Blvd.
Austin, TX 78751
► January Preferred Drug List Updates
The Medicaid Preferred Drug List (PDL) was updated January 22. Changes
include all Lantus products changing status from non-preferred to preferred,
and all Saphris products changing status from preferred to non-preferred. The
PDL is available online at TxVendorDrug.com/pdl/ and includes both
cough/cold and prenatal vitamins lists and a summary document detailing
changes by drug class and by drug name. The PDL, our formulary, and clinical
edit criteria are also available for free on the Epocrates drug information
system. The next update is scheduled for July 2015. ■
► Advisory Committees Updates
The Drug Utilization Review Board reviews and recommends outpatient
pharmacy clinical prior authorization edit criteria for drugs and drug classes.
The Pharmaceutical & Therapeutics Committee reviews drugs and drug classes
for preferred/non-preferred drug status. Both advisory committees meet
quarterly in Austin.
Drug Utilization Review Board
o Thursday, April 23, 2015
o Thursday, July 23, 2015
Pharmaceutical & Therapeutics Committee
o Friday, April 24, 2015
o Friday, July 24, 2015
► Continuing Education Credits
HHSC offers free computer-based training courses to enhance your ability to
provide pharmacy services to Medicaid eligible children in Texas. In addition,
pharmacists and pharmacy technicians can earn Category One Continuing
Medical Education (CME) credit. The courses are accredited by the
Accreditation Council of Pharmacy Education (ACPE). More than 40 CME
courses are offered at TxHealthSteps.com. ■
► Medicaid Comprehensive Care Program
The Medicaid Comprehensive Care Program can cover medically necessary
drugs and supplies that are not available through VDP for fee-for-service
Medicaid clients birth through 20 years of age. Pharmacies should inform the
family (or physician) that they can request coverage through CCP. Pharmacies
not enrolled as CCP providers may direct the client to call TMHP at 1 800 3358957 to locate a CCP provider. Pharmacies that want to enroll should complete
an application at TMHP.com. For assistance call the TMHP contact center at 1
800 925-9126 or your local TMHP representative. Pharmacies should inform
the family (or physician) to contact the client's managed care organization for
their specific comprehensive program coverage and procedures. ■
►Email Notification Service
The HHSC Email Notification Service is used to send notices to subscribers on
behalf of the Medicaid/CHIP Division and Vendor Drug Program. Notices are
sent when new content is published to our website and when important news is
to be shared with providers. To receive notices, users must actively subscribe
or "opt in" to the service. During the subscription process, the user must
provide an email address, a delivery preference, and have the option to provide
a password. Users may then choose the subscription categories that they wish
to receive. ■
The Rx Update is published four times a year (February, May, August,
and November) by the Texas Health and Human Services Commission
Medicaid/CHIP Division Vendor Drug Program at 4900 North Lamar
Boulevard, Austin, TX 78751.
POSTMASTER: Send address changes to: HHSC, P.O. Box 85200
(MC-2250), Austin, TX 78751.
► What We Do
The Medicaid/CHIP Vendor Drug Program enrolls pharmacy
providers that want to provide Medicaid and CHIP services; manages
the Texas Medicaid and CHIP formularies; and processes out-patient
pharmacy prescription claims for fee-for-service Medicaid, the Texas
Women's Health Program, the DSHS Children with Special Health
Care Needs (CSHCN) Services Program, and the DSHS Kidney
Health Care (KHC) program. Learn about what we do and find out
how to contact us at TxVendorDrug.com/about/.
VDP Pharmacy Benefit Access ..................................... 800-435-4165
KHC Program ............................................................... 800-222-3986
CSHCN Service Program .............................................. 800-252-8023
Texas Prior Authorization Call Center .......................... 877-728-3927
Texas Third-Party Call Center ...................................... 866-389-5594
Texas Third-Party Call Center ...................................... 866-389-5594
CCP Diabetic and Medical Supplies
Pharmacy PA Assistance ..................................... 800-846-7470
Client assistance .................................................. 800-335-8957
Medicare ....................................................................... 800-633-4227
► Managed Care Resources
Most Medicaid clients and all Children’s Health Insurance Program
(CHIP) clients receive their prescription drug benefits through the
managed care service delivery model. Resources for pharmacy staff
are available at the Vendor Drug Program website:
TxVendorDrug.com/claims/managed-care.shtml ■
► 72-Hour Emergency Overrides
A 72-hour emergency supply of a prescribed drug should be provided
when a medication is needed without delay and prior authorization
(PA) is not available. This applies to all drugs requiring authorization
either because they are non-preferred drugs on the Preferred Drug
List or because they are subject to clinical prior authorization edits.
Pharmacies will be paid in full for 72-hour emergency prescription
claims. Full instructions are available for downloading and displaying
in your pharmacy from TxVendorDrug.com. ■
► KHC & CSHCN Billing Reminders
KHC and CSHCN are not Medicaid programs. Please contact the
program directly or refer to claim submittal requirements at
TxVendorDrug.com/downloads/. ■