The July 2023 Medicaid Preferred Drug List (PDL) is now available. This update features changes that were approved at the January and April 2023 Drug Utilization Review Board meetings. The PDL also contains formulary and prior authorization information, notations for drugs requiring clinical prior authorization, the review schedule, and appendices for cough and cold products, iron oral agents, and prenatal vitamins.
Preferred Drug Reminders
The following items are preferred drug reminders:
- Prescribing providers must use the Medicaid formulary and the PDL. Providers that prescribe medications for people enrolled in the Children’s Health Insurance Program (CHIP) must use the CHIP formulary. CHIP does not have a PDL.
- The PDL does not include all the drugs on the Texas Medicaid formulary.
- Drugs on the Texas Medicaid formulary are designated as preferred or non-preferred, or they have neither designation. The PDL includes only drugs identified as either preferred or non-preferred.
- Drugs that are not designated as preferred or on the non-preferred list are available without prior authorization.
- Drugs that are identified as non-preferred will require prior authorization.
- Some preferred and non-preferred drugs may require clinical prior authorization.
- Certain drugs on the Medicaid formulary and the PDL are subject to one or both types of prior authorization: clinical and non-preferred. Prescribing providers must obtain prior authorization for these drugs. Pharmacy staff cannot request prior authorization.
The PDL Criteria Guide outlines the standards used to evaluate prior authorization requests for non-preferred drugs. The Texas Health and Human Services Commission (HHSC) has updated the guide to reflect the recent changes.
Obtaining Medicaid Outpatient Drug Prior Authorization
Prescribing providers must obtain prior authorization for outpatient drugs based on what Medicaid program the client is enrolled in.
For clients in a Medicaid managed care organization (MCO), prescribing providers or their representatives should contact the prior authorization call center that is unique to the client’s MCO. Prior authorization call center phone numbers vary by MCO. For a list of the various call centers and contact details, consult the MCO Resource Information document.
For clients 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 featured on the federal Health and Human Services (HHS) website. Formulary information is also available for all state programs administered by HHSC.
Epocrates is a free subscription drug information service that can be downloaded to a computer or mobile 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 8.1 of the Outpatient Drug Services Handbook in the Texas Medicaid Provider Procedures Manual to learn more.
Prescribers may use their e-prescribing software to view the Medicaid and CHIP formularies or to find preferred drugs and alternatives to non-preferred medications.
72-Hour Emergency Supply
The prescribing provider must request prior authorization for the prescribed drugs. If approval is not available when the prescription is submitted, pharmacy staff will alert the provider. If medication is needed without delay, pharmacy staff can provide a 72-hour emergency supply of the medication while the prescribing provider obtains the authorization. An emergency supply offers the client an immediate dose of the medicine, but they must return to the pharmacy and collect the entire prescription or receive alternative therapy.
Pharmacy Prior Authorization Quick Course
Need a quick refresher on the Medicaid pharmacy benefit, including prior authorization? Spend five minutes reading A Prescriber’s Guide to Texas Medicaid Outpatient Pharmacy Prior Authorization Quick Course.
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