Managed Care

Pharmacy participation

Pharmacy providers must have enrolled with Texas Medicaid before participating in any managed care pharmacy network.

• Learn about the different Medicaid programs, including STAR, STAR+PLUS, STAR Health, STAR Kids, and traditional Medicaid, as well as the combined Medicare-Medicaid health plan for people who have both Medicare and Medicaid coverage.
• The Service Delivery Area Assistance Chart (PDF) provides a breakout of the managed care organizations that serve each service delivery area (SDA).
• The Pharmacy Enrollment Chart (PDF) identifies how pharmacy providers with questions pertaining to a new, pending, or existing contract can contact each MCO and pharmacy benefits manager (PBM).
• Pharmacy providers must exhaust the complaints and/or grievance process with the MCO before filing a complaint with HHSC.

Prior Authorization

Some Medicaid drugs are subject to one or both types of prior authorization, clinical and non-preferred.  There are certain clinical prior authorizations that all Medicaid managed care organizations are required to perform.  Usage of all other clinical prior authorizations will vary between MCOs at the discretion of each MCO. 

Obtaining PDL/Clinical Prior Authorization

Prescribing providers or their representatives should contact the MCO's prior authorization call center.  The Prescriber Assistance Chart (PDF) identifies each MCO's prior authorization and member call center.  The MCO must notify the prescribing provider of authorization approval or denial within 24 hours of the time of the request.

Pharmacy Resources

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

Prescriber Resources

• Prescriber Assistance chart (PDF)
• Texas Medicaid Provider Procedures Manual

MCO Resources

• Managed Care Resources Update Request Form (XLS)
• Drug Non-Risk Payment (PDF)
• MCO Quarterly Clinical Prior Authorization Reporting Crosswalk (PDF)