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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 4: Client Eligibility : 4.4 Restricted Medicaid Coverage : 4.4.2 Client Limited Program : Pharmacy services
The primary care pharmacy helps the Limited Program ensure that prescriptions that are filled for clients with limited status are written either by the primary care provider or other health-care providers to whom the primary care provider has referred the client. HHSC has identified by therapeutic class those medications that require additional monitoring. When a medication that requires additional monitoring is prescribed by an emergency room provider, the primary care pharmacy may be reimbursed for dispensing up to 72 hours or three business days of the prescribed dosage, which allows for holidays and weekends. The primary care pharmacy may dispense the remainder of the medication after receiving approval by the primary care provider or the other providers that HHSC deems to be appropriate.
Some circumstances allow a client to be approved to receive medications from a pharmacy other than the primary care pharmacy. A pharmacy override occurs when the Limited Program approves an individual client’s request to obtain medication at an alternate pharmacy other than the lock-in pharmacy. The Limited Program is notified when the client or pharmacist calls the HHSC-OIG Hotline telephone number at 1-800-436-6184 to request a pharmacy override.
The Limited Program staff refers the client to the notification letter titled “What You Need to Know About the Limited Program,” which was sent at initial lock-in. This letter explains the pharmacy override process. The client is instructed to have the alternate pharmacy call the Limited Program to request the override.
The following are allowable circumstances for pharmacy override approval:
For questions about pharmacy services for clients that are limited to a primary care pharmacy, contact the Limited Program by calling the HHSC OIG Hotline at 1-800-436-6184.

Texas Medicaid & Healthcare Partnership
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