Texas Medicaid will implement the semi-annual update of the Medicaid Preferred Drug List (PDL) on July 30, 2020. The update is based on changes presented and recommended at the January 2020 and May 2020 Texas Drug Utilization Review Board meetings. Drug list decisions from the January meeting and recommendations from the May meeting are available. The recent temporary PDL changes addressing reported drug shortages will not affect the July PDL update. The PDL will not revise any drug in the short-acting beta agonists or glucocorticoids-inhaled class, or Concerta or Aggrenox.
Preferred Drug Reminders
- Prescribing providers must use the Texas Medicaid formulary and PDL. Providers who prescribe medications for clients enrolled in the Children’s Health Insurance Program (CHIP) must use the CHIP formulary. CHIP does not have a PDL.
- Not all drugs on the Texas Medicaid formulary are on the PDL.
- Drugs not on the PDL, or drugs identified on the PDL as "preferred," are available to clients without prior authorization.
- Drugs on the PDL identified as "non-preferred" will require prior authorization.
- Some preferred and non-preferred drugs may require clinical prior authorization.
- Some drugs on the formulary and PDL are subject to one or both types of prior authorization, clinical or non-preferred.
- Prescribing providers must obtain prior authorization for these drugs. Pharmacy staff cannot request prior authorizations.
The Preferred Drug List Criteria Guide outlines the criteria used to evaluate the non-preferred prior authorization requests. It will be updated by July 30, 2020, to reflect the recent changes.
Obtaining Medicaid Outpatient Drug Prior Authorization
The method for obtaining prior authorization for outpatient drugs depends on the Medicaid program in which the client is enrolled:
- For clients enrolled in a Medicaid managed care organization (MCO), prescribing providers or their representatives should contact the prior authorization call center for the client’s MCO. Prior authorization call center phone numbers vary by MCO. Each MCO’s prior authorization call center is listed on the Prescriber MCO Assistance Chart. The chart is available to download from txvendordrug.com/resources/downloads.
- For clients of traditional Medicaid, prescribing providers or their representatives should call the Texas Prior Authorization Call Center at 877-PA-TEXAS (877-728-3927).
Online Drug Reference Information
The following Medicaid and CHIP drug information is available online:
- The Medicaid and CHIP formulary and Medicaid PDL information is available online. Formulary information is also available for all state programs administered by the Texas Health and Human Services Commission.
- Epocrates is a free subscription drug information service that can be downloaded to a computer or handheld device. In addition to listing a drug’s preferred status, Epocrates includes drug monographs, dosing information, and warnings. All prescribing providers are eligible to register for Epocrates online at epocrates.com.
- Prescribers may use e-prescribing software to view the Medicaid and CHIP formularies or to find preferred drugs and alternatives to non-preferred drugs.
72-Hour Emergency Supply
The prescribing provider is responsible for obtaining drug prior authorization. Pharmacy staff will alert the prescribing provider to obtain prior authorization if authorization was not obtained when the prescription was presented to the pharmacy. If medication is needed without delay, pharmacy staff are allowed to provide a 72-hour emergency supply of the medication while the prescribing provider obtains the authorization. Dispensing an emergency supply provides the client with an immediate dose of the medication but requires a return trip to the pharmacy for the full prescription or alternate therapy.
Quick Refresher on Pharmacy Prior Authorization
Need a quick refresher on the Medicaid pharmacy benefit, including prior authorization? Spend five minutes with the A Dispenser's Guide to Texas Medicaid Outpatient Pharmacy Prior Authorization Quick Course.