Medicaid covers drugs and biologics administered in both inpatient and outpatient settings, however those administered in an inpatient setting are usually not reimbursed separately to hospitals. Instead, they are bundled into an All-Patient Refined Diagnosis Related Group (APR-DRG) payment.
Effective June 2, 2025, HCCAD will be carved out of the All-Patient Refined Diagnosis Related Group (APR-DRG) and eligible for separate reimbursement for the following:
Separate Prior Authorizations are required for both the inpatient admission and the HCCAD. The admission authorizations cover the hospital stay, while the HCCAD needs its own authorization for appropriate use and coverage.
If you have questions, please email PRSupport@BSWHealth.org.
Medicaid providers are experiencing significant challenges complying with Medicaid provider enrollment revalidation requirements and timelines. In response, HHSC is implementing provider enrollment revalidation flexibilities and requiring all Medicaid and CHIP payers to support these flexibilities. HHSC is taking action to extend revalidation due dates, reduce or eliminate enrollment gaps and require payers to support claims reprocessing efforts.
More information: Retroactive Enrollment Periods and Claims Reprocessing.
To comply with the 21st Century Cures Act (Section 12006) federal law, HHSC has started identifying programs, services and service delivery options related to home health care services required to use EVV by Jan. 1, 2023 (PDF). HHSC will continue to analyze these services and additional updates may be made.
Visit the 21st Century Cures Act webpage for the latest information about the EVV home health care services implementation.
To receive related notifications and current EVV updates, sign up for EVV alerts.
Email questions to HHSC EVV Operations.
Texas Medicaid will publish the semi-annual update of the Medicaid preferred drug list on Jan. 28, 2021. The update is based on changes presented and recommended at the July and October 2020 Texas Drug Utilization Review Board meetings. Drug list decisions from those meetings are available.
Rightcare follows the Texas VDP formulary. The Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for the use of the Pfizer-BioNTech COVID-19 Vaccine on Dec. 11, 2020.
HHSC will add the vaccine to the formulary for the Medicaid, Children's Health Insurance Program (CHIP) and Healthy Texas Women (HTW) programs as a payable pharmacy benefit beginning Dec. 28, 2020. VDP will backdate the effective date of formulary coverage to Dec. 11, 2020, to align with medical benefit requirements, meaning pharmacy claims with dates of service starting Dec. 11, 2020, are allowed beginning Dec. 28, 2020.
Rightcare follows the Texas VDP formulary. The Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for the use of the Moderna COVID-19 vaccine on Dec. 18, 2020.
RightCare follows the Texas VDP formulary. Beginning Feb. 4, 2021, Texas Medicaid will no longer subject Oseni, a combination of Thiazolidinediones (TZD) and Dipeptidyl Peptidase-4 (DPP-4) inhibitor drug, to the TZD clinical prior authorization criteria (PDF). Oseni is not recommended for patients with severe renal impairment or end-stage renal disease requiring dialysis. Therefore, the TZD criteria are deemed inappropriate for this drug. Oseni will continue to be subject to the DPP-4 Inhibitors clinical prior authorization criteria (PDF).
This prior authorization is optional for use in Medicaid managed care. The Pharmacy Clinical Prior Authorization Assistance Chart shows the prior authorization each MCO uses and how those authorizations relate to the authorizations used for traditional Medicaid claim processing. This chart is updated quarterly. Providers can also refer to the MCO Resources for links to each MCO's list of clinical prior authorizations.
RightCare follows the Texas VDP formulary. On Sept. 25, 2020, the FDA approved Kalydeco (ivacaftor) to treat children four months through six months of age with cystic fibrosis who have at least one cystic fibrosis transmembrane conductance regulator (CFTR) gene mutation. Previously, Kalydeco was approved only for children six months and older. On Dec. 28, 2020, VDP will update the Kalydeco clinical prior authorization criteria to reflect the newly FDA-approved indication for use in children age four months to less than six months with at least one CFTR gene mutation responsive to Kalydeco.
This prior authorization is optional for use in Medicaid managed care. The Pharmacy Clinical Prior Authorization Assistance Chart (PDF) shows the prior authorization each health plans uses and how those authorizations relate to the authorizations used for traditional Medicaid claim processing. This chart is updated quarterly. Providers can also refer to the MCO Resources for links to each MCO's clinical prior authorizations.
Healthy Texas Women (HTW) is a core women's health and family planning program for low income women without health insurance. Informational flyer.
The July 30, 2020 Texas Medicaid Preferred Drug List was revised, effective Oct. 30, 2020.
RightCare follows the Texas VDP formulary. An update to the Clinical Prior Authorization Assistance Chart (PDF) is available.
There are certain clinical prior authorizations that all MCOs are required to perform. Usage of other clinical prior authorizations will vary between health plans at the discretion of each MCO. Each prior authorization guide includes a description of the steps in the prior authorization evaluation process:
For more information about each MCO's clinical prior authorization requirements, providers can:
The Texas Drug Utilization Review Board met Oct. 22-23, 2020, to make recommendations about clinical prior authorizations and drugs to be included on the Texas Medicaid Preferred Drug List.
RightCare follows the Texas VDP formulary. Texas Health and Human Services issued the Texas Medicaid Standing Order for Mosquito Repellent for people enrolled in Medicaid, CHIP and the Healthy Texas Women Program earlier this year. The standing order serves as a prescription and allows pharmacists to dispense mosquito repellent under its terms. People enrolled in these programs do not have to visit their healthcare provider to receive mosquito repellents. Pharmacies should use the standing order instead of contacting the healthcare provider for a prescription for mosquito repellent.
The Texas Drug Utilization Review Board met Friday, July 24, 2020 to make recommendations about drugs to be included on the Medicaid preferred drug list. The approved list of decisions is now available. HHSC will incorporate the decisions from both the July and October 2020 board meetings into the January 2021 release of the preferred drug list.
The quarterly NDC-to-HCPCS Crosswalk is now available for clinician-administered drug processing. The next new crosswalk will be available January 2021.
Rightcare follows the Texas VDP formulary. VDP temporarily removed the non-preferred status for brand Concerta products in the Stimulants drug class on April 23, 2020, in response to reported drug shortages. VDP will reverse this change in status because of sufficient availability in the market. VDP made this determination after verifying the current availability of the preferred Methylphenidate ER tablet products, as well as the non-preferred brand Concerta products through multiple sources such as ASHP, FDA, manufacturers, wholesalers and pharmacies in various regions around Texas.
VDP will restore the non-preferred status on the drugs below on Oct. 16, 2020, because of sufficient product availability. For a complete list of all preferred products in the Stimulants drug class, refer to the July 2020 Preferred Drug List. Contact vdp-formulary@hhsc.state.tx.us for questions or comments.
The July 30, 2020 Texas Medicaid Preferred Drug List was revised, effective Sept. 17, 2020.
RightCare follows the Texas VDP formulary. VDP temporarily removed the non-preferred status on April 1, 2020 in response to reported drug shortages for medications in the "Glucocorticoids, Inhaled" drug class. VDP will reverse this change in status because of sufficient availability in the market. VDP made this determination after verifying the current availability of the preferred inhaled glucocorticoid products, as well as the non-preferred inhaled glucocorticoid products through multiple sources such as ASHP, FDA, manufacturers, wholesalers and pharmacies in various regions around Texas. Beginning Sept. 18, 2020, the formulary will reflect the PDL status changes for all non-preferred inhaled glucocorticoid products.
Updating to correct non-preferred status for Asmanex HFA.
RightCare follows the Texas VDP formulary. VDP temporarily removed the non-preferred status on April 1, 2020 in response to reported drug shortages for insulin products in the "Hypoglycemics, Insulins" drug class. VDP will reverse this change in status because of sufficient availability in the market. VDP made this determination after verifying the current availability of the preferred insulin products, as well as the non-preferred insulin products through multiple sources such as ASHP, FDA, manufacturers, wholesalers and pharmacies in various regions around Texas. Beginning Sept. 18, 2020, the formulary will reflect the PDL status changes for all non-preferred insulin products.
Updating to correct non-preferred status for Novolin Flexpen.
The July 30, 2020 Texas Medicaid Preferred Drug List was revised, effective Sept. 8, 2020.
VDP regularly updates the clinical prior authorization criteria. These updates are necessary to help align VDP drug policies and prior authorization approval criteria with the latest information available on drug information packets, the federal or state regulations.
On Oct. 1, 2020, ICD-10 code G40.83 becomes available for Dravet Syndrome with the following sub-codes:
RightCare will update the clinical edits for Epidiolex and Diacomit to include these ICD-10 codes on Oct. 1, 2020. On July 31, 2020, the FDA approved Epidiolex for the treatment of seizures associated with tuberous sclerosis complex in patients one year of age and older. RightCare will add this new indication to the Epidiolex clinical edit on Oct. 1, 2020.
RightCare's Clinical Edits.
Beginning Sept. 1, 2020, RightCare will expand the Medicaid benefit to allow pharmacists to administer certain medications in a pharmacy setting, including the administration of:
The 2020-21 Respiratory Syncytial Virus (RSV) begins Oct. 1, 2020, for many counties in Texas. RightCare will make the following changes this season to Synagis coverage and prior authorizations:
The schedule is staggered and is based on a patient's county of residence at the start of the RSV season. Refer to the Synagis season schedule for each region's start and end dates.
RightCare Synagis Prior Authorization Forms
VDP regularly updates the clinical prior authorization criteria. These updates are necessary to help align VDP drug policies and prior authorization approval criteria with the latest information available on drug information packets, the federal or state regulations. RightCare will implement the following opioid prior authorization criteria revisions on Sept. 1, 2020, to align with the uniform opioid policy.
Opioid Policy Criteria
The Opioid Policy criteria will be implemented with the following:
Opiate Over-Utilization Criteria
The Opiate Over-utilization criteria will be revised Sept. 1, 2020. The criteria document was revised to include a question regarding cancer, sickle cell, palliative care and hospice care diagnosis. This change will align the prior authorization criteria with the new opioid policy.
RightCare Clinical Edit
RightCare temporarily removed the non-preferred status on April 2 in response to reported drug shortages for medications in the "Glucocorticoids, Inhaled" drug class. RightCare will reverse this change in status because of sufficient availability in the market. Beginning Sept. 18, 2020, the formulary will reflect the PDL status changes for all non-preferred inhaled glucocorticoid products.
RightCare temporarily removed the non-preferred status on April 2 in response to reported drug shortages for insulin products in the "Hypoglycemics, Insulins" drug class. RightCare will reverse this change in status because of sufficient availability in the market. Beginning Sept. 18, 2020 the formulary will reflect the PDL status changes for all non-preferred insulin products.
HHSC is participating in the National Academy of State Health Policy (NASHP) Maternal Child Health Policy Innovation program and is seeking provider input to gain a better understanding of the current landscape for substance use identification, substance use disorder (SUD) treatment and referral practices for pregnant and postpartum women enrolled in Medicaid, CHIP (including CHIP-P) or the Healthy Texas Women Program. Your response to the below survey will assist HHSC in developing better training and communication around SUD identification, existing treatment benefits, as well as referral and intervention processes and analyzing whether benefit and policy changes are needed.
In response to reported drug shortages for albuterol products in the Bronchodilators, Short-Acting Beta Agonist Inhalers drug class, RightCare temporarily removed the non-preferred status from the generic formulations on March 20, 2020. RightCare will reverse this change in status because we determined sufficient availability in the market.
On Sept 15, 2020, RightCare will extend the non-preferred prior authorization duration for macrolides from 30 days to 90 days for people with a diagnosis of Gastroparesis, Cerebral Palsy Gastroparesis or GERD Gastrostomy complications. This will accommodate longer-term prescribing for such conditions.
Beginning Sept. 21, 2020, VDP will require the "Quantity Prescribed" field (460–ET) on all pharmacy claims for Schedule II drugs.
CMS published a final rule(link is external) on Jan. 24, 2020, titled "Administrative Simplification: Modification of the Requirements for the Use of Health Insurance Portability and Accountability Act of 1996 National Council for Prescription Drug Programs D.0 Standard" requiring the "Quantity Prescribed" field (460–ET) when processing pharmacy claims for Schedule II drugs. The final rule applies to all health insurance plans, including Medicaid and CHIP.
VDP routinely updates existing clinical prior authorization criteria to reflect recent FDA-approved indications or safety information from the product package insert. RightCare will revise the Eucrisa (crisaborole) criteria within the Topical Immunomodulators clinical prior authorization on Aug. 13, 2020:
RightCare Clinical Edits
VDP routinely updates existing clinical prior authorization criteria to reflect recent FDA-approved indications or safety information from the product package insert. RightCare will revise the Austedo (deutetrabenazine) criteria within the Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors clinical prior authorization on Aug. 13, 2020:
VDP routinely updates existing clinical prior authorization criteria to reflect recent FDA-approved indications or safety information from the product package insert. RightCare will revise the Dupixent (dupilumab) clinical prior authorization on Aug. 13, 2020:
Preferred drugs are medications recommended by the Drug Utilization Review Board. The preferred drug list is published every January and July.
On May 28, RightCare temporarily revised the preferred drug list to address reported possible drug shortages of products in the Platelet Aggregation Inhibitors drug class. The change allows providers to prescribe these drugs without requiring a non-preferred prior authorization and people enrolled in Medicaid continued access to necessary medication. A list of the affected drugs is below. This is a temporary change until the preferred products are sufficiently available in the market. Prescribers are encouraged to use the VDP Formulary Search.
Covered Drugs
RightCare has identified drug shortages of nitrofurantoin oral suspension and azithromycin products on the Medicaid and CHIP formularies. There are many other antibiotic choices available on the formulary and prescribers may choose an appropriate alternative based on patient diagnosis and indication for use. Prescribers are encouraged to use the VDP Formulary Search to identify other antibiotic options to avoid delays in people receiving medication.
Details on where to submit any corrected claims and redeterminations with a date of service prior to Nov. 1, 2019.
HHSC has been informed of a drug shortage for Methylphenidate ER in the Stimulants drug class. RightCare temporarily removed the non-preferred status from the brand formulations of the NDCs below on April 22, 2020. These changes will allow providers to prescribe for these drugs without requiring a PDL prior authorization and allow continued access to necessary medication for clients. This is a temporary change until the preferred products are sufficiently available in the market. RightCare will announce any further PDL status changes of these NDCs.
RightCare will revise the clinical prior authorization criteria for protein convertase subtilisin/kexin type 9 (PCSK9) inhibitors on May 22, 2020.
Clinical Edit Criteria
Revisions include:
The Food and Drug Administration announced a drug shortage for Tacrolimus, part of the in the Oral Immunosuppressives drug class. In response RightCare has temporarily removed the non-preferred status from the generic formulations of the NDCs below effective April 17. These changes will allow providers to prescribe for these drugs without requiring a PDL prior authorization and allow continued access to necessary medication for clients. This is a temporary change until the preferred products are sufficiently available in the market. RightCare will announce any further PDL status changes of these NDCs.
The 2019-20 respiratory syncytial virus season ends for all counties on April 14, 2020, and prior authorization requests for Synagis are no longer be accepted or reviewed.
RightCare has implemented the temporarily revised preferred drug list on April 13,2020, to address reported possible drug shortages of products in the Topical Nonsteroidal Anti-inflammatory drug class. The change allows providers to prescribe these drugs without requiring a non-preferred prior authorization and people enrolled in Medicaid continued access to necessary medication. This is a temporary change until the preferred products are sufficiently available in the market.
The Food and Drug Administration requested manufacturers withdraw all ranitidine products (commonly known by the brand name Zantac) from the market because of consumer exposure to unacceptable levels of impurities. RightCare removed all ranitidine products from the Medicaid and CHIP formularies on April 4, 2020. Formulary alternatives available include famotidine (10mg, 20mg and 40mg), cimetidine (200mg, 300mg, 400mg and 800mg) and nizatidine (150mg and 300mg).
RightCare has implemented the temporarily revised preferred drug list on April 2, 2020 to address reported possible drug shortages of products in the inhaled glucocorticoid and hypoglycemic insulin drug classes. The change allows providers to prescribe these drugs without requiring a non-preferred prior authorization and people enrolled in Medicaid continued access to necessary medication. This is a temporary change until the preferred products are sufficiently available in the market.
Beginning April 1, Texas pharmacies, as well as any out of state pharmacy, can temporarily enroll with the Vendor Drug Program using our expedited enrollment application (HHS Form 1350). The expedited form and enrollment process allows pharmacies to quickly provide pharmaceutical services to people enrolled in Texas Medicaid during the COVID-19 pandemic. In addition, CMS has waived the collection of the enrollment application fee during the state of emergency.
RightCare will implement the Growth Hormone clinical prior authorization criteria on April 1, 2020.
The implementation will include four diagnosis codes for approval as suggested by MCOs and approved by VDP:
On March 21, VDP temporarily changed the preferred drug list to address reported drug shortages for short-acting agents in the bronchodilators, beta agonist drug class. This change allows providers to prescribe these drugs without requiring a non-preferred prior authorization and allow people on Medicaid continued access to necessary medication. VDP will continue to update providers on the status these drugs.
RightCare implemented the clinical prior authorization criteria for Sunosi (solriamfetol) on March, 9 2020.
The criteria is part of the Central Nervous System Stimulants clinical prior authorization. The drugs Provigil and Nuvigil are already part of this clinical prior authorization.
RightCare added a new exception criteria to the Jan. 24 preferred drug list, to check for a diagnosis of stage-four advanced metastatic cancer or for treatment of symptoms associated with the cancer diagnosis. Prescribers must contact the pharmacy prior authorization call center and attest the person meets the exception criteria for the non-preferred drug to be approved because diagnoses are not readily available in a person's medical claims data.
RightCare implemented the Trikafta criteria within the existing Cystic Fibrosis Agents clinical prior authorization on Feb 24, 2020.
The Texas Drug Utilization Board approved the criteria for Trikafta at the January 2020 meeting. Trikafta is a cystic fibrosis transmembrane conductance regulator (CFTR) modulating agent. As part of the criteria is a check for duplicative or concurrent therapies with another CTFR modulating agent. The board recommended the inclusion of this step to the criteria for all CFTR modulator agents.
Refer to the Provider Reference Guide for information on claims, eligibility and other RightCare services.
Mylan issued an alert regarding the manufacturing challenges in the production of EpiPen (epinephrine injection, USP) 0.3 mg and EpiPen Jr (epinephrine injection, USP) 0.15 mg auto-injectors and the authorized generic versions of these strengths. These challenges resulted in the reduced availability of these products.
RightCare temporarily removed the non-preferred status from the following:
This change will allow providers to prescribe these product NDCs without requiring non-preferred prior authorization and will allow continued access to medication. The current preferred NDCs are:
This is a temporary change until the preferred products are sufficiently available again in the market. There may be outages varying between pharmacies despite Mylan products no longer identified as a shortage according to FDA and ASHP. Further announcements regarding future PDL status changes of these NDCs will be sent out.
Resources:
The semi-annual update of the Medicaid preferred drug list is now available. The update is based on changes presented and recommended at the July and October 2019 Texas Drug Utilization Review Board meetings.
Drugs on the Texas Medicaid formulary are designated as preferred, non-preferred or have neither designation. The preferred drug list includes only drugs identified as preferred or non-preferred.
RightCare will implement the Rinvoq (upadacitinib) clinical prior authorization criteria on March 3, 2020.
Rinvoq is a Janus Kinase inhibitor for treatment of adults with moderate-to-severe active rheumatoid arthritis who have not responded adequately or are intolerant, to methotrexate. The Texas DUR Board approved the criteria at the Oct. 2019 meeting.
RightCare will modify the Austedo prior authorization criteria on March 3, 2020. The criteria are included within the existing Vesicular Monoamine Transporter 2 (VMAT2) inhibitors criteria guide.
The Texas Drug Utilization Review Board approved the criteria in January 2014. The class includes Austedo, Xenazine and Ingrezza.
Austedo is approved for treatment of Huntington-Induced Chorea and Tardive Dyskinesia (TD). RightCare will modify the prior authorization criteria to address the Austedo boxed warning about increased risk of depression in patients with only Huntington-Induced Chorea and prevent unnecessary prior authorization denials for patients with TD.
RightCare will revise the Allergen Extracts clinical prior authorization criteria on Feb. 24, 2020. This change reflects the Food and Drug Administration guidance expanding the indication for Oralair for people 5 years of age and older. The previous indication was for 10 years of age and older. Additionally, RightCare will change the contraindication diagnosis to include only severe, uncontrolled asthma diagnoses.
Oralair is part of the Allergen Extract clinical prior authorization criteria.
Read the Provider Newsletter for trending articles and Medicaid product and benefit information.
View the COVID-19 Telehealth and Telemedicine Policy for coding guidelines and claims submission procedures. We have also reduced our Prior Authorization Requirements.