Medicaid Drug Prior Authorization Procedure

Medicaid Vendor Drug Program (Medicaid fee-for-service pharmacy claims)

Prescribers may still request preferred drug and/or clinical edit prior authorization  by calling 1-877-PA-TEXAS (1-877-728-3927). Prescribers will also have the option to submit prior authorization requests online through a secure, easy-to-use interface that is available 24 hours a day. To submit an online non-preferred drug prior authorization request , prescribers should visit HID PaXpress and register for an account.

Medicaid Managed Care Organization (MCO)\ Pharmacy Benefit Manager (PBM)

Medicaid managed care organizations contract with Pharmacy Benefit Managers (PBM) to administer pharmacy benefits for Medicaid managed care recipients.

• Prior Authorization Call Center phone numbers may vary by Medicaid managed care health plan.
• Prior Authorization is required for non-preferred drugs and drugs subject to clinical PA edits.  MCOs/PBMs may implement any of the Vendor Drug Program’s clinical PAs, but not more stringent.
• MCOs must notify the prescriber’s office of a PA approval/denial within 24 hours of the time of the phone request.

Resources

The Texas Medicaid fee-for-service and managed care models use the same  formulary and Preferred Drug List. Both are available on the Epocrates drug information system. The service is free and provides instant access to information through internet or on handheld device about the products on the Texas Medicaid formulary. Visit http://www.txvendordrug.com/formulary/epocrates.shtml for more information.

Vendor Drug Program Searchable Formulary

VDP has a new visual tutorial on Medicaid pharmacy benefits.