Pharmacy

Pharmacy overview

Dell Children’s Health Plan has an arrangement with Navitus Health Solutions to administer pharmacy benefits for Dell Children’s Health Plan CHIP and STAR members. Members may obtain their medications at any network pharmacy unless HHSC has placed the member in the Office of Inspector General (OIG) Lock-in program.

For questions related to the formulary, the preferred drug list, billing, prescription overrides, prior authorizations, quantity limit or formulary exceptions, call Navitus at 1-877-908-6023 or access the Navitus website at www.navitus.com.

Pharmacy links

Pharmacy providers are responsible for but not limited to the following:

Filling prescriptions in accordance with the benefit design
Adhering to the Vendor Drug Program (VDP) formulary and Preferred Drug List (PDL)
Coordinating with the prescribing physician
Ensuring members receive all medication for which they are eligible
Coordinating benefits when a member also receives other insurance benefits
Providing a 72-hour emergency supply of prescribed medication any time a prior authorization is not available, if the prescribing provider cannot be reached or is unable to request a prior authorization, and a prescription must be filled without delay for a medical condition.

Note: Certain drugs, such as hepatitis C drugs, are excluded from the 72-hour emergency supply rule.

Prescription limits

All prescriptions are limited to a maximum 34-day supply per fill except for CHIP members, and all prescriptions for non-controlled substances are valid only for 11 refills or 12 months from the date the prescription was written, whichever is less.

CHIP member prescriptions

CHIP members are eligible to receive an unlimited number of prescriptions per month and may receive up to a 90-day supply of a drug.

Office of Inspector General (OIG) Lock-in program

The HHSC OIG Lock-in program restricts, or locks in, a Medicaid member to a designated pharmacy if it finds that the member used drugs covered by Medicaid at a frequency or in an amount that is duplicative, excessive, contraindicated, or conflicting, or that the member’s actions indicate abuse, misuse or fraud. Some circumstances allow a member to be approved to receive medications from a pharmacy other than the lock-in pharmacy. A pharmacy override occurs when Navitus approves a member’s request to obtain medication at an alternate pharmacy other than the lock-in pharmacy. To request a pharmacy override, the member or pharmacy should call Navitus at 1-877-908-6023. The following are allowable circumstances for pharmacy override approval:

The member moved out of the geographical area (more than 15 miles from the lock-in pharmacy).
The lock-in pharmacy does not have the prescribed medication and the medication will not be available for more than 2-3 days.
The lock-in pharmacy is closed for the day and the member needs the medication urgently. Covered drugs. The Dell Children’s Health Plan pharmacy program utilizes the Texas Medicaid/CHIP Vendor Drug Program (VDP) formulary and Preferred Drug List (PDL). The PDL is a list of the preferred drugs within the most commonly prescribed therapeutic categories, reviewed and approved by the Drug Utilization Review Board. Please refer to the VDP formulary and PDL at www.txvendordrug.com.

Over-the-counter (OTC) medications specified in the Texas State Medicaid plan are included in the formulary and are covered if prescribed by a licensed prescriber.

OTC medications are generally not covered for CHIP members; however, an exception exists for insulin. To prescribe medications that do not appear on the PDL or those that require clinical prior authorization, call Navitus at 1-877-908-6023 for prior authorization. Only those drugs listed in the latest edition of the Texas Drug Code Index (TDCI) are covered. Venosets, catheters and other medical accessories are not covered and are not included when submitting claims for intravenous and irrigating solutions. Except for vitamins K and D3, prenatal vitamins, fluoride preparations and products containing iron in its various salts, we do not reimburse for vitamins or legend and non-legend multiple-ingredient anti-anemia products. Vitamins and minerals for members under age 21 are reimbursable. We may limit coverage of drugs listed in the TDCI per the VDP. Procedures used to limit utilization may include prior approval, cost containment caps or adherence to specific dosage limitations according to FDA-approved product labeling. Limitations placed on the specific drugs are indicated in the TDCI.

The following are examples of covered items:

Legend drugs
Insulin
Disposable insulin needles/syringes
Disposable blood/urine glucose/acetone testing agents
Lancets and lancet devices
Compounded medication of which at least one ingredient is a legend drug and listed on the PDL
Any other drug, which under the applicable state law, may only be dispensed upon the written prescription of a physician or other lawful prescriber and is listed on the VDP formulary

PDL listed legend contraceptives

Exception: Injectable contraceptives may be dispensed up to a 90-day supply.

You may also verify covered items at www.navitus.com or by calling 1-877-908-6023.

Specialty drug program

We cover most specialty drugs under the pharmacy benefit. These drugs may be obtained at any network pharmacy that handles these types of drugs. The conditions typically treated with specialty injectable drugs are: growth hormone deficiency, cancer, multiple sclerosis, hemophilia, rheumatoid arthritis, hepatitis and cystic fibrosis.

Excluded drugs

The following drugs are excluded from the pharmacy benefit:

Any drug marketed by a drug company (or labeler) that does not participate in the federal drug rebate program, in accordance with Section 1927 of the Social Security Act, 42 U.S.C.A. §1396r-8

Drug products that have been classified as less-than-effective by the Food and Drug Administration (FDA) Drug Efficacy Study Implementation (DESI)

Drugs excluded from coverage following Section 1927 of the Social Security Act, 42 U.S.C.A. §1396r-8 such as:
- Weight control products (except orlistat, which requires prior authorization)
- Drugs used for cosmetic reasons or hair growth
- Experimental or investigational drugs
- Drugs used for experimental or investigational indication
- Infertility medications
- Erectile dysfunction drugs to treat impotence
Non-legend drugs other than those listed above, or specifically listed under Covered non-legend drugs

Prescription Drug Monitoring Program

Texas Requirement: Effective March 1, 2020 pharmacists and prescribers are required to check the patient’s Prescription Monitoring Program history before dispensing or prescribing opioids, benzodiazepines, barbiturates or carisoprodol. This helps to eliminate duplicate and overprescribing of controlled substances. For more information watch the Texas Prescription Monitoring Program Video.
CMS Requirement: Under section 1944 of the Support for Patients and Communities Act, beginning on October 1, 2021, Medicaid providers must check Medicaid beneficiaries’ prescription drug history in the qualified PDMP before prescribing controlled substances to the beneficiary. The requirement can be found here.

Emergency prescription supply

A 72-hour emergency supply of a prescribed drug must be provided when a medication is needed without delay, and prior authorization (PA) is not available. This applies to all drugs requiring a PA, either because they are nonpreferred drugs on the Preferred Drug List or because they are subject to clinical edits. The 72-hour emergency supply should be dispensed any time a PA cannot be resolved within 24 hours for a medication on the Vendor Drug Program (VDP) formulary that is appropriate for the member’s medical condition. If the prescribing provider cannot be reached or is unable to request a PA, the pharmacy should submit an emergency 72-hour prescription. A pharmacy can dispense a product that is packaged in a dosage form that is fixed and unbreakable (e.g., an albuterol inhaler) as a 72-hour emergency supply.

To be reimbursed for a 72-hour emergency prescription supply, pharmacies should submit the following information:

“8” in “Prior Authorization Type Code” (Field 461 EU)
“8Ø1” in “Prior Authorization Number Submitted” (Field 462 EV)
“3” in “Days’ Supply” (Field 4Ø5 D5, in the Claim segment of the billing transaction)
The quantity submitted in “Quantity Dispensed” (Field 442 E7) should not exceed the quantity necessary for a three-day supply, according to the directions for administration given by the prescriber. If the medication is a dosage form that prevents a three-day supply from being dispensed (e.g., an inhaler), it is still permissible to indicate that the emergency prescription is a three-day supply and enter the full quantity dispensed.

Call 1-877-908-6023 for more information about the 72-hour emergency prescription supply policy.

Durable medical equipment/other products normally found in a pharmacy.

Dell Children’s Health Plan reimburses for covered durable medical equipment (DME) and products commonly found in a pharmacy. For all qualified members, this includes medically necessary items such as nebulizers, ostomy supplies, bed pans and other supplies and equipment. For children and young adults birth through age 20, Dell Children’s Health Plan also reimburses for items typically covered under the Texas Health Steps Program, such as prescribed over-the-counter drugs, diapers, disposable or expendable medical supplies and some nutritional products. Pharmacies must be enrolled as DME providers and submit claims for most DME to Dell Children’s Health Plan as a medical benefit; however, the durable medical supplies included in the VDP list of limited home health supplies can be submitted to Navitus as a pharmacy benefit.

To be reimbursed for DME under the pharmacy benefit, a pharmacy must first enroll in the Navitus network by contacting Navitus at 1-877-908-6023 or via email at providerrelations@navitus.com.

For all other DME, the provider must be enrolled in the Dell Children’s Health Plan network by contacting Network Development at shpnetworkdevelopment@seton.org.

Call 1-844-781-2343 for information about DME and other covered products commonly found in a pharmacy for children (birth through age 20).