Texas Medicaid will publish the semi-annual update of the Medicaid Preferred Drug List (PDL) on July 29, 2021. The Texas Health and Human Services Commission (HHSC) based the update on changes presented and recommended at the January 2021 and April 2021 Texas Drug Utilization Review Board meetings. Drug list decisions from the January and April meetings are available.
Preferred Drug Reminders
- Prescribing providers must use the Medicaid formulary and the PDL. Providers who prescribe medications for people enrolled in the Children’s Health Insurance Program (CHIP) must use the CHIP formulary. CHIP does not have a preferred drug list.
- The PDL does not include every drug on the Texas Medicaid formulary.
- Drugs on the Texas Medicaid formulary are designated as preferred, non-preferred, or have neither designation. The PDL includes only drugs identified as either preferred or non-preferred:
- Drugs not on the preferred list or drugs identified on the list as “preferred” are available without prior authorization.
- Drugs on the preferred list 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 the 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 may not request prior authorizations.
The Preferred Drug List Criteria Guide outlines the criteria used to evaluate the non-preferred prior authorization requests. The HHSC will update the guide by July 2021 to reflect the recent changes.
Obtaining Medicaid Outpatient Drug Prior Authorization
Prescribing providers obtain prior authorization for outpatient drugs based on the Medicaid program:
- For people enrolled in a Medicaid managed care organization (MCO), prescribing providers or their representatives should contact the MCO’s prior authorization call center. Prior authorization call center phone numbers vary by MCO. A list of each prior authorization call center is available on the Prescriber MCO Assistance Chart. The chart is available to download from txvendordrug.com/resources/downloads.
- For people in 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 information is available online:
- The Medicaid and CHIP formulary and Medicaid PDL are available online. Formulary information is also available for all state programs administered by HHSC.
- Epocrates is a free subscription drug information service you can download to your 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. Refer to section 9.1 of the “Outpatient Drug Services Handbook” in the “Texas Medicaid Provider Procedure Manual” to learn more.
- Prescribers may use their e-prescribing software to view the Medicaid and CHIP formularies or find preferred drugs and alternatives to non-preferred medications.
72-Hour Emergency Supply
The prescribing provider is responsible for obtaining prior authorization. The pharmacy staff alerts the prescribing provider to obtain prior authorization if approval was not obtained when the prescription is presented to the pharmacy. If medication is needed without delay, the pharmacy staff can provide a 72-hour emergency supply of the medication while the prescribing provider obtains the authorization. Dispensing an emergency supply offers the person an immediate dose of the medicine but requires a return trip to the pharmacy for the entire prescription or alternate therapy.
Pharmacy Prior Authorization Quick Course
Need a quick refresher on the Medicaid pharmacy benefit, including prior authorization? Spend five minutes with A Prescriber’s Guide to Texas Medicaid Outpatient Pharmacy Prior Authorization.
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