Downloads

Pharmacy Enrollment Resources

• Enrollment Forms
  • Delivery Sign
• Pharmacy Provider Procedure Manual
• Pharmacy Provider Payer Sheets
• Eligibility Verification
  • Pharmacy Eligibility Verification Portal Access (HHS Form 1317)
• Pharmacy Payment
  • Pharmacy Electronic Remittance Advice Agreement (HHS Form 1316)

Managed Care Resources

• Pharmacy Enrollment Chart (PDF)
• Pharmacy Assistance Chart (PDF)
• Prescriber Assistance Chart (PDF)
• Service Delivery Area Assistance Chart (PDF)

Drug and Product Resources

• Drug Addition Process Overview
  • The Texas Medicaid program covers most outpatient prescription drugs either through a Medicaid managed care organization (MCO) or through the Vendor Drug Program (VDP). The HHSC Drug Addition Process (PDF) provides a high-level summary of the process that occurs prior to adding drugs to the Texas Medicaid formulary.
• Texas Drug Code Index Certification of Information (HHS Form 1326)
• Drug Shortage Notification (HHS Form 1315)
• Specialty drug list
• Clinician-administered drug resources
• Long-acting reversible contraception product resources
• Mosquito Repellent Benefit
  • Mosquito Repellent Benefit Assistance Chart (PDF)
  • Notices for:
    • Clients (English) (PDF)
    • Clients (Español) (PDF)
    • Pharmacies (English) (PDF)
    • Prescribers (English) (PDF)

Prior Authorization

• Non-preferred
  • Preferred Drug List
  • PDL PA Criteria Guide (PDF)
• Clinical
  • Clinical PA Assistance Chart (PDF)
• Forms
  • ​Traditional Medicaid
  • CSHCN Services Program
• Texas Prior Authorization Call Center
  • Registration
  • Provider Quick Reference
  • Texas Medicaid Prior Authorization Reconsideration Request (HHS Form 1322)

Drug Rebates

• Drug Rebates
  • CHIP Drug Rebate Agreement (PDF)
  • CSHCN Drug Rebate Agreement (PDF)
  • KHC Program Drug Rebate Agreement (HHS Form 1329)

Drug Utilization Review Board

• Drug Utilization Review Board
  • Meeting documents
  • Drug utilization criteria/compendia

Education and Training Materials

• 72-hour Emergency Override Instructions (PDF)
• Texas Medicaid Pharmacy Benefits brochure (PDF)
• Continuing Education flyer (PDF)
• Getting Started with Electronic Prescribing of Controlled Substances (PDF)

Claim Forms

• Pharmacy Retroactive Claim Form (HHS Form 1318)
• Pharmacy Claims Billing Request (HHS Form 1319)

Delimited Text Files

• Formulary (zip) - (Updated June 11, 2018)
• HTW Program Formulary (XLS) - (Updated May 7, 2018)
  • Formulary file layout (PDF)
  • HTW Program Formulary file layout (PDF)
• Pharmacy Index (txt) - (Updated June 11, 2018)
  • Pharmacy file layout (PDF)
• Prescriber Index (zip) - (Updated June 11, 2018)
  • Prescriber file layout (PDF)