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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.39 Clinician-Administered Drugs : 9.2.39.2 Injectable Medications as a Pharmacy Benefit

9.2.39.2
Some injectable drugs or biologicals are available by prescription and are reimbursable as a pharmacy benefit through the Vendor Drug Program (VDP) under Texas Medicaid.
Refer to:
Oral medications that are given in the hospital or physician’s office are considered part of the hospital or office visit and cannot be reimbursed separately. Take-home and self-administered drugs may be a pharmacy benefit when they are provided to eligible Texas Medicaid fee-for-service clients through VDP with a valid prescription.
Providers may utilize the “white bagging” delivery method, in which the treating provider submits prescriptions to pharmacies and the prescription is shipped or mailed to the provider’s office.
Refer to:
Subsection B.1.2, “Pharmacy Delivery Method for Clinician-Administered Drugs” in “Appendix B: Vendor Drug Program” (Vol. 1, General Information) for additional information on the “white bagging” delivery method.
Providers must use oral medication in preference to injectable medication in the office and outpatient hospital. If an oral medication cannot be used, the KX modifier must be submitted on the claim. The following situations are acceptable reasons for the use of administering an injectable medication instead of administering an oral medication.
 
The client has a temperature over 102 degrees Fahrenheit (documented on the claim and in the medical record) and a high blood level of antibiotic is needed quickly.
The client has demonstrated noncompliance with orally prescribed medication (must be documented on the claim and in the medical record).
Previously attempted oral medication regimens have proven ineffective (must be supported by documentation in the medical record).
The claim and the client’s medical record must include documentation of medical necessity to support the need for the service. Retrospective review may be performed to ensure that the documentation supports the medical necessity of the service and any modifier used when billing the claim.

Texas Medicaid & Healthcare Partnership
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