Effective Date: 



Updated: 5/2018



The form is used by Texas 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:

  1. Drug(s) must have a Centers for Medicare & Medicaid Services rebate agreement in place.
  2. Drug(s) must be listed with First Data Bank and Medi-Span.
  3. The form must be accompanied with package insert(s).
  4. The form must be accompanied with FDA approval letter(s).


  • Mail:

VDP Formulary Management (MC-2250)
Texas Health and Human Services
4900 North Lamar Blvd.
Austin, TX 78751

  • Email:



Detailed Instructions

  1. All fields in the “Drug Description”, “Pricing Information”, and “Certification” sections should be completed in their entirety to be considered for coverage.
  2. Complete the fields in the “Contacts” section as applicable.
  3. The entire review process may take up to 90 days once the COI is fully determined to be complete.



Questions about this form should be directed to the Vendor Drug Program by email at vdp_formulary@hhsc.state.tx.us.

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