The Texas Vendor Drug Program implemented the Medicaid Preferred Drug List (PDL) in February 2004. Preferred drugs will be available without prior authorization, while non-preferred drugs will require prior authorization, which may involve the prescriber or one of their staff representatives calling the Texas Prior Authorization Call Center to obtain approval before the drug can be dispensed. Approved requests for prior authorization will be valid for one year.

Contents:

• Contacting the Texas Prior Authorization Call Center
• Claim submission at point-of-sale
• Requesting a Prior Authorization for a non-preferred drug
• Call Center Determination
• Emergency Supply
• Request for Reconsideration

Resources:

• Frequently Asked Questions
• Prior Authorization Quick Reference Guide
• 72-hour Emergency Override instructions
• Request for Reconsideration form

Contacting the Texas Prior Authorization Call Center

Only the prescribing physician or one of their staff representatives can request a prior authorization. All Prior Authorization requests must be called in to the Texas Prior Authorization Call Center at 1-877-PA-TEXAS (1-877-728-3927) Monday - Friday 7:30 a.m. - 6:30 PM (CST). Prior authorization requests for non-preferred agents will not be handled via the Vendor Drug Pharmacy Resolution Desk.

Claim submission

• Submitting Claims for a preferred drug at the point-of-sale
  If the claim is for a preferred agent the point-of-sale transaction will be approved, the drug claim will pay, and no further action will be required. The pharmacy should fill the prescription per standard store or facility procedures.
• Submitting Claims for a non-preferred drug at the point-of-sale
  If a prior authorization is not on file, has expired, or the claim does not meet the PDL approval criteria, the claim will be denied at point-of-sale. The recipient should contact his or her prescriber's office since additional information may be required for evaluation of the prior authorization before any approval can be issued.

Requesting a Prior Authorization for a non-preferred drug

Requests submitted with missing information will not be assessed until that information can be provided. The information below will be required by the Texas Prior Authorization Call Center in order to quickly assess the prior authorization request. Requests submitted with missing information will not be assessed until that information can be provided.

• Recipient-specific information:
• Texas Medicaid assigned recipient ID number
• Recipient Name
• Recipient Date of Birth
• Reason for requesting override for a non-preferred drug
• Prescriber-specific information:
• Texas Medicaid assigned provider ID number (5-character Texas license number)
• Physician Name (or name of delegating physician)
• Claim-specific information:
• Requested drug and strength
• Days supply
• Number of refills

Call Center Determination

If the Texas Prior Authorization Call Center approves the prior authorization, the patient can return to their pharmacy to obtain the prescription. The drug claim will pay and no further action will be required. Approved requests for prior authorization will be valid for one year.

If the Texas Prior Authorization Call Center denies the request, the physician's office will be notified immediately. The prescriber has the option of prescribing a different treatment course that does not require prior authorization or submitting the Request for Reconsideration form.

Emergency Supply

In cases where a prior authorization is medically necessary the Texas Vendor Drug Program will allow for a 72-hour emergency supply of a non-preferred drug.

Request for Reconsideration

The prescriber may request reconsideration if the Texas Prior Authorization Call Center denies a prior authorization request. If a request for prior authorization is denied after going through the call center process, the call center staff will inform the physician that he has the right to request reconsideration of the decision rendered. The call center representative will provide the physician with the steps to request reconsideration of a prior authorization decision. The Prior Authorization Request for Reconsideration form is required to initiate the request and provides a brief description of the steps for reconsideration.

Please fax the Request for Reconsideration Form (updated September 2005) to the Texas Prior Authorization Center at 1-866-617-8864. (This fax number is only to be used for Requests for Reconsideration after the call center has denied a phone request. Initial prior authorization requests will not be accepted via fax.)

Once a prior authorization request goes through the call center process and is denied, no verbal requests for reconsideration can be accepted. Supporting documentation should include the following:

• Request for Reconsideration form.
• A copy of the client's applicable medical records or lab results documenting the medical reason for the treatment.
• If applicable, supporting peer-reviewed literature for the treatment.

Determinations of the Request for Reconsideration form will be mailed to the requesting prescriber and patient. If the Request for Reconsideration form is denied, the patient's letter will include information on the Texas Vendor Drug Program appeal process.

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