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Effective Date: 




Updated: 10/2017



The Vendor Drug Program (VDP) Pharmacy Claims Billing Request is the only acceptable method to submit paper claims to VDP. Paper submission is only allowed for certain state-approved situations as defined in the Pharmacy Provider Procedure Manual. All other paper forms, and Pharmacy Claims Billing Requests submitted for unapproved reasons, are not accepted and will be returned with no action taken. The form is kept for five years after the end of the federal fiscal year in which the pharmacy provider submits the form.


Detailed Instructions

Pharmacy staff should complete the form in its entirety, as applicable. Form fields should be completed using NCPDP standard values when applicable. Refer to the values in the NCPDP B1 Transaction Billing Request payer sheet. The “Submission Explanation” field is required and identifies why the form is being submitted.



Fax: 512-491-1952
Mail: Texas Health and Human Services, Vendor Drug Program, Mail Code 2250, 4900 North Lamar Blvd., Austin, TX 78751.



Questions about this form should be directed to the VDP Pharmacy Benefits Access Help Desk at 800-435-4165.