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Effective Date: 



Updated: 10/2017



The Vendor Drug Program (VDP) utilizes the Medicaid Retroactive Claim Form to assist pharmacy providers with an expedited process for the payment of retroactive fee-for-service Medicaid claims. The form is only for use for people eligible for fee-for-service Medicaid and with retroactive Medicaid coverage and will be returned with no action taken if used for other purposes.


Detailed Instructions

  • The total number of pending claims and the date of service of the oldest claim must be included to determine accurate certification and effective dates. There will be a lengthened turnaround if the information is not provided on Medicaid Retroactive Claim Form.
  • Refer to Texas Administrative Code §354.1877 ( for information pertaining to quantity limitations and refills:
    • Except for medications that may be too unstable to be dispensed as a one-month supply, the Texas Health and Human Services Commission requires that the same drug in the same strength be dispensed no more than once per month.
  • Claims with the same national drug code for service dates within the same month must be combined for one billing per month. Claims that are not combined will not be paid.
  • If after research, the claims are approved for payment, and the number of pending claims is given, the rejected claims will be paid. The completed form will be returned to the pharmacy within two weeks. If the claims are not approved an explanation will be provided when the form is returned.


By Fax:

  • 512-491-1958
  • Attention: VDP Pharmacy Benefits Access


Direct all questions about this form to the VDP Pharmacy Benefits Access Help Desk at 800-435-4165.