As a reminder to MCOs, the mosquito repellent for the prevention of Zika virus became a continuous, year-round benefit for Texas Medicaid and CHIP on February 12, 2018.

The renewed 2018-2019 Texas Medicaid Standing Order for Mosquito Repellent is attached and available for use with the statewide mosquito repellent benefit. This standing order should be distributed to pharmacies for use with the benefit. Note that the previous standing order used in 2017 expired April 10, 2018. Please ensure that pharmacies are informed about the revised standing order, and that they have access to the revised document.

Documents for clients, pharmacies, and prescribers are available online.

Benefit details

  • Start date: February 12, 2018.
  • Covered programs - Medicaid, CHIP, and CHIP-Perinatal.
  • Eligible members:
    • pregnant women of any age;
    • females, ages 10 through 55; and
    • males, age 14 and older.
  • The pharmacy benefit for approved mosquito repellents is limited to one can/bottle per prescription fill, with up to two fills allowable per calendar month.
  • A prescription is required for claim approval of mosquito repellent when the standing order is not used by a pharmacy.

Expectations

MCOs are to offer all mosquito repellents that appear on the Texas formulary as a pharmacy benefit to eligible clients in the covered programs noted above. Formulary repellents will continue to be designated with "ZIK" on the DEL file.

Claim Submission

  • Days' supply per can is unknown and submitted values will likely vary greatly.  It is recommended that claims processing systems bypass edits on this data element or apply reasonable billing requirements and edits that do not severely restrict access to the covered products.
  • Pregnant females in Medicaid should be identified with type programs "40" or "42".
  • A claim should not exceed total payment of $6.50 per can/bottle, including ingredient cost, dispensing fee and any other fees.  Note: Reimbursement below $6.50 per claim is authorized if the health plan can demonstrate adequate availability of covered mosquito repellents at that pharmacy acquisition cost.
  • Claims should bypass third-party billing edits for covered mosquito repellent claims.

MCOs are asked to communicate details of the benefit to members. MCOs do not require communication approval from MCCO if the only information changing on the previously approved notice is related to benefit coverage dates. Additional revisions to the member notice require review and approval prior to distribution.

Please continue to use www.TexasZika.org as a resource for information related to the Zika virus.

Documents: