Medicaid providers are required to include a National Drug Code (NDC) for
certain Healthcare Common Procedure Coding System (HCPCS) procedure codes.
Effective January 1, 2014,
Texas Medicaid and the CSHCN Services Program follow the CMS Drug Rebate Program.
Texas Medicaid, and the Children with Special Health Care Needs (CSHCN) 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.
Providers can refer to the Texas Vendor Drug Program (VDP) website at www.txvendordrug.com for the quarterly-updated
HHSC NDC-to-HCPCS Crosswalk list of clinician-administered drug procedure codes that require a rebate-eligible NDC.
Providers can refer to the
CMS Medicaid Drug Rebate Program Data
website or to the document titled"
“CMS List of Rebatable NDCs" available on this website to determine which NDCs are
eligible for rebate.
Physician-administered drugs that do not have a rebate-eligible NDC will not be reimbursed by Texas Medicaid or the CSHCN Services Program.
Providers who believe that NDCs are missing for a specific HCPCS procedure code may send an email to
firstname.lastname@example.org to request that research be performed. The provider will need to provide the procedure code in question and the
corresponding NDCs that the provider believes are missing from the HHSC crosswalk.
Providers should also be aware that the requirement for inclusion of rebate-eligible NDCs also applies to Medicaid managed care. Medicaid managed care
organizations (MCOs) will use the same list of procedure codes as TMHP when processing claims for clinician-administered drugs. For claims processed by an
MCO, providers must refer to the MCO for specific questions or details regarding the enforcement of this requirement in managed care.