Downloads

Pharmacy Enrollment

• 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

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

Formulary Resources

• Drug Shortage Notification (HHS Form 1315)
• Specialty Drugs
  • Specialty drug process (PDF)
  • Specialty drug submission spreadsheet (XLS)
• Clinician-administered Drugs
  • NDC-to-HCPCS crosswalk
• Long-acting reversible contraception products
• Mosquito Repellent Benefit

Prior Authorization

• Non-preferred
  • Preferred Drug List
  • PDL 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)
• Education
  • Dispensing 72-hour Emergency Prescriptions (PDF)

Manufacturer Resources

Drug Utilization Review Board

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

Education and Training Materials

Claim Forms

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

Delimited Data Files