Pharmacy Information Services

Clinician-Administered Drugs

Medicaid Services Program may reimburse providers only for clinician-administered drugs and biologicals whose manufacturers participate in the Centers for Medicare & Medicaid Services (CMS) Drug Rebate Program and that show as active on the CMS list for the date of service the drug is administered. Clinician-administered drugs that do not have a rebate-eligible National Drug Code (NDC) will not be reimbursed by Texas Medicaid Program. Please note there may be ingredients in a compound that are not considered a drug under the Federal Food, Drug, and Cosmetic Act.

Texas Medicaid will published two types of files to our website:

• The NDC-to-HCPCS Crosswalk identifies relationships between National Drug Codes (NDC) and Medicaid payable Healthcare Common Procedure Coding System (HCPCS) codes. The crosswalk is published monthly, based on quarterly additions to the CMS list of rebate-eligible drugs and new drugs that are added monthly to the First Data Bank pricing compendia.
• The Pharmacy Clinical Prior Authorization Assistance Chart shows the prior authorization each health plan uses and how those authorizations relate to the authorizations used for Medicaid claim processing. Please visit the Vendor Drug Program in order to view the current chart.
• The inclusion of a HCPCS code on the crosswalk does not guarantee coverage or payment. Please refer to the Fee Schedule published by TMHP to insure the procedure is a payable for the submitted program.
• The crosswalk is intended to assist providers with accurate claims submission, including the three NDC-related fields, required for Medicaid claims. Please refer to the Clinician-Administered Drug Provider Training for instructions on how to complete the claim.
• The Drug Labeler Directory identifies all labelers that participate in the CMS Drug Medicaid Rebate Program. The file is produced quarterly, about 45 days after the end of the calendar quarter.

Please visit the Vendor Drug Program in order to search for old crosswalks.

CAD Drug Reminder

Please visit the Navitus website for the following pharmacy information

• Clinical edits
• Formulary
• Pharmacy directory
• Prior authorization forms

Texas Health and Human Services Vendor Drug Program

• Preferred Drug List
• Medicaid Formulary

Pharmacy Provider Relations

Navitus Provider Relations can assist you with:

• Network participation
• Network access reports
• Contract questions
• Pharmacy credential review
• Reimbursement and remittances
• Maximum Allowable Cost list (MAC)
• Network system set up
• Pharmacy performance analysis and reporting
• Pharmacy Communications

Pharmacy Provider Relations/Contracts: 866-333-2757
Fax: 866-808-4649
Email: providerrelations@navitus.com

Navitus Texas Provider Hotline: 877-908-6023 (toll free)
Prior Authorization: 877-908-6023 (toll free)
Pharmacy Network (request a contract, 835 setup, remit issues): 608-729-1577
Fraud, Waste, and Abuse: 855-673-6503

Maximum Allowable Cost

Maximum Allowable Cost list (MAC) pricing issues-If you experience negative reimbursement for a drug on the MAC list, please complete and fax us a MAC override Request Form, located on the Navitus Portal The NDC in question must be on the Preferred Drug List to be eligible for consideration.  Be sure to provide proof of acquisition price (copy from your wholesaler).

If you have questions please call Provider Services at 1-888-243-3312 Monday-Friday from 8 a.m. to 5 p.m. or Contact us here