Claim Processing

This applies to drugs that are non-preferred on the preferred drug list and/or because they are subject to clinical prior authorization. Pharmacies will be paid in full for 72-hour emergency prescription claims.

To learn what is required to submit a 72-hour emergency claims, pharmacy staff should refer to section 12 of the Pharmacy Provider Procedure Manual (PDF) (PPPM).
A 72-hour emergency prescription claim can be used for either fee-for-service Medicaid or Medicaid managed care members:

  • Authorization for Fee-for-service Medicaid claims should be directed to the Texas Prior Authorization Call Center.
  • Pharmacies submitting claims for Medicaid clients enrolled in managed care should refer the prescriber to the client’s health plan’s prior authorization call center.

Pharmacy Education

We encourage pharmacy staff to post these instructions in your pharmacy for reference and to reproduce this information for staff education. It is important that your staff understands the 72-hour emergency supply policy and procedures and uses them appropriately.