Pharmacy participation
Pharmacy providers must enroll with Texas Medicaid before participating in managed care pharmacy networks.
- Learn about the different Medicaid programs, including STAR, STAR+PLUS, STAR Health, STAR Kids, and the combined Medicare-Medicaid health plan for people with both Medicare and Medicaid coverage.
- The Service Area Assistance Chart (PDF) provides a breakout of the managed care organizations serving each service delivery area (SDA).
- The Pharmacy MCO 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).
Complaint Process
Medicaid managed care providers must exhaust the complaints or grievance process with their managed care medical or dental plan before filing a complaint with HHSC. If after completing this process, the provider believes they did not receive full due process from the managed care medical or dental plan, they may file a STAR, STAR+PLUS, STAR Health, STAR Kids or managed care dental complaint or inquiry by using the Online Question or Complaint Form or by emailing HPM_Complaints@hhsc.state.tx.us.
Refer to Provider Information to learn more about MCO Complaints and Appeals.
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 all Medicaid MCOs are required to perform. Usage of all other clinical prior authorizations will vary between MCOs at the discretion of each MCO.
Prescribing providers or their representatives should contact the MCO's prior authorization call center. The Prescriber MCO 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
- Pharmacy MCO Enrollment Chart (PDF)
- Pharmacy MCO Assistance Chart (PDF)
- Service Area Assistance Chart (PDF)