Pharmacy Enrollment
- Enrollment Forms
- 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
- Clinician-administered Drugs
- Long-acting reversible contraception products
- Mosquito Repellent Benefit
Prior Authorization
- Non-preferred
- Clinical
- Forms
- Texas Prior Authorization Call Center
- Education
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
- Pharmacy Retroactive Claim Form (HHS Form 1318)
- Pharmacy Claims Billing Request (HHS Form 1319)
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) |