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Mosquito Repellent Is Available As A Statewide Benefit: Covered Programs

The Texas Health and Human Services Commission covers mosquito repellents for Medicaid, CHIP, Healthy Texas Women, and Children with Special Health Care Needs programs to prevent the Zika virus. Pharmacies can dispense repellents under a statewide standing order or with an individual prescription. Eligible individuals can receive up to two repellents per month at no cost under Medicaid or with potential copays for CHIP. Claims are processed using NDCs for covered repellent products listed on the Vendor Drug Program website.

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66 views5 pages

Mosquito Repellent Is Available As A Statewide Benefit: Covered Programs

The Texas Health and Human Services Commission covers mosquito repellents for Medicaid, CHIP, Healthy Texas Women, and Children with Special Health Care Needs programs to prevent the Zika virus. Pharmacies can dispense repellents under a statewide standing order or with an individual prescription. Eligible individuals can receive up to two repellents per month at no cost under Medicaid or with potential copays for CHIP. Claims are processed using NDCs for covered repellent products listed on the Vendor Drug Program website.

Uploaded by

Juan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Mosquito Repellent is Available as

a Statewide Benefit

Texas Health and Human Services covers mosquito repellents for the prevention of
the Zika virus. The following notice describes claims processing, eligibility and
benefit information specific to the mosquito repellent benefit for the covered
programs listed below. Prescription templates are available on the Vendor Drug
Program website.

Covered programs
1. Medicaid (traditional and managed care)
2. Children's Health Insurance Program and CHIP-Perinatal
3. Healthy Texas Women program
4. Children with Special Health Care Needs services program

Program specifics
Medicaid and CHIP

Use of a Standing Order for the Mosquito Repellent Benefit

Texas HHS issued the Texas Medicaid Standing Order for Mosquito Repellent to be
used for people enrolled in Medicaid and CHIP. This order serves as a prescription
and allows pharmacists to dispense mosquito repellent under the terms of the
order. Pharmacies are encouraged to use this order instead of contacting the
person’s healthcare providers for individual prescriptions for mosquito repellent.

Pharmacists should reference the standing order for details. Refer to the VDP
website for a prescription template for pharmacies.

The current standing order is effective Apr. 1, 2019.

Mar. 25, 2019 | Pharmacy Notice - 1


Pharmacies may request a copy of the standing order by emailing vdp-
[email protected].

A prescription from a valid healthcare provider is required for any


pharmacy/pharmacist not operating under a standing order for the dispensing of
mosquito repellent to people enrolled in Medicaid or CHIP.

HTW Program

A prescription isn’t required for people enrolled in the HTW Program. The below
information should be used to process HTW Program claims:

Provider name field: Zika, Zika (Last Name, First Name)

Address: 4900 N. Lamar Blvd, Austin, TX 78751

NPI: 1234568883

License: 2126X

The standing order may not be used for people enrolled in the HTW Program. Refer
to the VDP website for a prescription template. Pharmacy staff can print the
template for its records, if needed.

CSHCN Services Program

A prescription is required for people enrolled in the CSHCN services program.


Contact the person’s health care provider to obtain a prescription for mosquito
repellent.

Mar. 25, 2019 | Pharmacy Notice - 2


Mosquito Repellent Benefit Details

Eligible populations
● Females ages 10 - 55 years old and pregnant females of any age
● Males ages 14 and older

Quantity
● Coverage of mosquito repellents will be limited to two can or bottles per
calendar month: only one can or bottle may be dispensed per fill, with one
optional refill available per calendar month.
● Mosquito repellent claims will not count against a person’s monthly three-
prescription limit for Medicaid fee-for-service.

Benefit duration
● The mosquito repellent benefit is continuous year-round benefit.

Client responsibility
● Approved claims for people eligible for Medicaid, HTW and CSHCN services
programs will be provided at no cost to the person.
● People enrolled in CHIP may be subject to a copay depending upon family
income. Any potential copays should not exceed the cost of the product.

Covered Products
Covered products have been selected based on guidance from the Centers for
Disease Control. Please refer to the Mosquito Repellent Benefit Products Assistance
Chart (PDF) for a current list of covered mosquito repellents.

Claims Processing
Prescription details

● For the dispensing under the Standing Order:

Mar. 25, 2019 | Pharmacy Notice - 3


 Refer to the Mosquito Repellent prescription template available on the
Vendor Drug Program website.
● Pharmacies should process the claim per the prescription details if a written
prescription is provided.

Reimbursement
● Reimbursement may vary for MCOs, but may not exceed $6.50 per
can/bottle.
● The Medicaid FFS reimbursement to pharmacies will be the usual and
customary price to the general public or up to a maximum of $6.50 per
can/bottle of mosquito repellent (inclusive of product cost and dispensing
fee); total calendar month maximum of $13.00. Products will not be eligible
for payment of a delivery fee or incentive fee.
● Pharmacies will be required to submit their usual and customary cost for the
items.

Product Submission

● Each product’s 12-digit Universal Product Code (UPC) has been converted
into an 11-digit National Drug Code (NDC) for claims submission. Refer to
the Mosquito Repellent Benefit Products Assistance Chart (PDF) for NDCs for
submission.
● Mosquito repellent will be treated as a generic medication and pharmacies
have the authority to fill the prescription with any covered product, unless
the prescriber has stated "do not substitute" to specify the active ingredient
(not the manufacturer).

Unit of Measure

● Pharmacies should submit the standard unit in the “Unit of Measure” field
(6ØØ-28) when processing claims. For example, a 170 gram bottle should be
submitted with a quantity of 170.

Days Supply

● A can of repellent is expected to last 15 days or more. Pharmacies are


recommended to submit a 15-day supply.

Mar. 25, 2019 | Pharmacy Notice - 4


Overrides

● The claims processor (fee-for-service or the MCO) may have to perform a


manual override for pregnant women 9 or younger or 55 or older. In these
situations pharmacies should contact the MCO provider line or, for fee-for-
service, the HHS Pharmacy Benefits Access Help Desk at 800-435-4165.

For more information


● Texas Department of State Health Services
 TexasZika.org
● Centers for Disease Control and Prevention
 cdc.gov/zika/
● Vendor Drug Program
 txvendordrug.com/formulary/formulary/mosquito-repellent

Mar. 25, 2019 | Pharmacy Notice - 5

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