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December 2016 Texas Medicaid Provider Procedures Manual

Medicaid Managed Care Handbook : 2 Overview of Medicaid Managed Care : 2.1 Managed Care Services : 2.1.2 Prescription Drug/Pharmacy Services : Prescription Drug Prior Authorizations
Prescribers may be required to request prior authorization for a prescription drug. The prescriber must contact the client’s MCO or PBM and follow MCO or PBM guidelines and procedures for prior authorization requests.
TMHP does not have access to the MCOs’ or PBMs’ guidelines and procedures for prior authorizations. The provider must contact the MCOs of PBMs for information. Individual PBMs will have their own PA processes and telephone lines.
The MCO must notify the prescriber’s office of a prior authorization approval or denial:
Prior authorization is required for non-preferred drugs or any drug requiring a clinical prior authorization.
If the pharmacy cannot dispense the client’s prescription because prior authorization is required but has not been requested, the pharmacy should contact the MCO or PBM to request prior authorization. The prescribing provider is required to submit certain prior authorization requests including, but not limited to, non-preferred drug prior authorizations.
If the prescribing provider cannot be reached or is unable to request a prior authorization, the pharmacy should submit an emergency 72-hour prescription. The request for an emergency 72-hour prescription claim should not be used for routine and continuous overrides.
A 72-hour emergency prescription will be paid in full to pharmacy providers and does not count toward the three-prescription limit for adults who have not already received their maximum prescriptions for the month.
Federal and Texas law allow a 72-hour emergency supply of prescribed medication to be dispensed any time a prior authorization is not available and the prescription must be filled without delay for a medical condition. This rule applies to non-preferred drugs on the Preferred Drug list and any drug for which prior authorization must be requested by the prescribing physician.
The MCOs or PBMs are responsible for informing network providers about how to access the formulary and PDL.
Refer to:
MCOs may also selectively contract with pharmacies for specialty drugs.

Texas Medicaid & Healthcare Partnership
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