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December 2016 Texas Medicaid Provider Procedures Manual

Appendix B: Vendor Drug Program : B.1 Vendor Drug Program : B.1.12 Requirements for Early Refills of Certain Drugs

B.1.12
Medicaid fee-for-service and the Children with Special Health Care Needs (CSHCN) Services Program clients must exhaust 90 percent of the prescribed of certain controlled substances, including tramadol, before a Medicaid Vendor Drug Program (VDP)- enrolled pharmacy may refill a prescription or fill a new prescription for the same drug.
Note:
The 90% Utilization Drug List, which contains a complete list of the affected drugs, is available on the Vendor Drug Program’s formulary lookup by selecting the “90% Utilization” indicator on the drug list lookup and the returned results will include only those drugs that meet this requirement.
Justifications for early refills include, but are not limited to, the following:
If a client requests an early refill of a drug on the VDP list, the dispensing pharmacy must contact the VDP Pharmacy Resolution help desk to request an override of the early refill restriction. Prescribing providers may be asked to verify the reason for the early refill by the dispensing pharmacy or VDP staff.
Note:
Providers who are members of Medicaid managed care plans should contact the appropriate managed care organization (MCO) and/or Pharmacy Benefit Manager for specific requirements and processes related to dispensing early refills.

Texas Medicaid & Healthcare Partnership
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