The form is used by HHS Vendor Drug Program staff to evaluate coverage of a drug for inclusion on the Texas Drug Code Index (TDCI), or formulary.
When to Prepare
Representatives from drug manufacturers must use this form to submit requests for consideration for coverage on the TDCI when a drug is new to the market or when an existing drug on the TDCI has a new formulation.
To be considered:
- Drug(s) must have a Centers for Medicare & Medicaid Services rebate agreement in place.
- Drug(s) must be listed with First Data Bank and Medi-Span.
- The form must be accompanied with package insert(s).
- The form must be accompanied with FDA approval letter(s).
VDP Formulary Management (MC-2250)
Texas Health and Human Services
4900 North Lamar Blvd.
Austin, TX 78751
- All fields in the “Drug Description”, “Pricing Information”, and “Certification” sections should be completed in their entirety to be considered for coverage.
- Complete the fields in the “Contacts” section as applicable.
Questions about this form should be directed to the Vendor Drug Program by email at firstname.lastname@example.org.