Jul. 13: Starting this fall all prescribing providers must be enrolled by Texas Health and Human Services for those services to be eligible for payment. Learn more about how prescriber enrollment status will impact pharmacy claim responses.
Jul. 3: Need a quick refresher on the Medicaid pharmacy benefit, including prior authorization? Spend five minutes with the Prescriber’s Guide to Texas Medicaid Outpatient Pharmacy Prior Authorization Quick Course.
Medicaid Drug Formulary
The Vendor Drug Program Formulary is available to assist providers help their patients obtain medications. Our formulary tools include information about which state programs cover each drug (e.g. Medicaid, CHIP) and whether a Medicaid non-preferred or clinical prior authorization is required. Formulary information is available:
Outpatient Drug Prior Authorization
The Vendor Drug Program Formulary used for fee-for-service (FFS) Medicaid and Medicaid managed care clients consists of preferred and non-preferred drugs. Non-preferred drugs require prior authorization. Some drugs on the Medicaid formulary (whether preferred or non-preferred) may also be subject to clinical prior authorization edits that require prior authorization.
Fee-For-Service (FFS) Medicaid
To obtain prior authorization for most medications prescribing providers or their representatives should call the Texas Prior Authorization Call Center. Some medications that require clinical prior authorization are reviewed internally by the Vendor Drug Program.
Medicaid Managed Care
To obtain prior authorization prescribing providers or their representatives should contact the managed care plan. Prior Authorization call center phone numbers may vary by health plan. The Prescriber Assistance Chart (PDF) identifies prior authorization and member call center phone numbers for each plan.
72-Hour Emergency Supply
It is the prescribing provider’s responsibility to obtain the prior authorization. In the event prior authorization has not been obtained at the time the prescription is presented at the pharmacy, pharmacies will alert the prescribing provider to obtain prior authorization. Dispensing an emergency supply provides the client with an immediate dose of the medication but requires a return trip to the pharmacy for the full prescription or alternate therapy. A 72-hour emergency prescription claim can be used for both Medicaid FFS service and managed care clients.
Free Continuing Education Credits
Texas Health Steps’ award-winning online program offers free CE Courses to enhance your ability to provide preventive health, mental health, oral health, and case management services to children who are Medicaid eligible in Texas. Free CE courses are available from the Texas Health Steps website.
Criteria for Vitamin and Minerals Products for Medicaid
Vitamin and mineral products prescribed or ordered by a physician to treat various conditions are a benefit of Texas Medicaid through the Comprehensive Care Program (CCP) for clients who are 20 years of age and younger. The vitamin and mineral products included in this program are manually priced, when they are prior authorized (PA) and submitted to TMHP with the corresponding procedure code and state-identified modifier. A portion of the CCP PA form must be completed by the prescribing provider. See the Benefit Criteria for Vitamin and Mineral Products to Change for Texas Medicaid article in September/October 2011 edition of the TMHP Texas Medicaid Bulletin for additional information.