Outpatient Drug Prior Authorization
The formulary used for people enrolled in Medicaid 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 criteria requiring prior authorization.
- Traditional Medicaid: prescribing providers or their representatives should call the Texas Prior Authorization Call Center. Some medications requiring clinical prior authorization are reviewed internally by the Vendor Drug Program.
- Medicaid managed care: prescribing providers or their representatives should contact the managed care plan. Prior Authorization call center phone numbers may vary by health plan. The Prescriber MCO Assistance Chart (PDF) identifies prior authorization and member call center phone numbers for each plan.
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 is available for all people enrolled in Medicaid.
Free Continuing Education Credits
Texas Health Steps’ award-winning online program offers free continuing education 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 continuing education courses are available from the Texas Health Steps website. 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.