Pharmacy Enrollment

Managed Care

Formulary Resources

Prior Authorization

Manufacturer Resources

Name Number
Drug Addition Process (PDF)  
Texas Drug Code Index Certification of Information HHS 1326
Reconciliation of State Invoice CMS-304
Prior Quarter Adjustment Statement CMS-304a
Manufacturer Contact Form (Magellan Medicaid Administration)  
CHIP Drug Rebate Agreement (PDF) HHS 1337
CSHCN Drug Rebate Agreement (PDF) HHS 1343
KHC Program Drug Rebate Agreement HHS 1329
Value-Based Agreement Concept HHS 1402

Drug Utilization Review Board

    Education and Training Materials

    Name Revised
    Dispensing 72-hour Emergency Prescriptions (PDF) 07/2019
    Pharmacy Resources for Managed Care (PDF) 07/2019
    Real-time Eligibility Verification (PDF) 07/2019
    Mosquito Repellent Benefit (PDF) 07/2019

    Claim Forms

    Delimited Data Files

    Data File Layout File
    Formulary Drug Index (txt) (Updated July 27) Layout (PDF)
    Formulary Product Index (txt) (Updated July 27) Layout (PDF)
    Formulary Clinical Prior Authorization Index (txt) (Updated July 27) Layout (PDF)
    Formulary HTW Program (XLS) (Updated June 2020) Layout (PDF)
    Formulary NDC-to-HCPCS Crosswalk (Updated quarterly) Layout (PDF)
    Pharmacy Pharmacy Index (txt) (Updated July 27) Layout (PDF)
    Prescriber Prescriber Index (ZIP) (Updated July 27) Layout (PDF)