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Semi-Annual Medicaid Preferred Drug List Update Coming July 25, 2024

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This article has been updated. To view the updated information, see “Update to ‘Semi-Annual Medicaid Preferred Drug List Update Coming July 25, 2024’

Texas Medicaid will publish the semi-annual update of the Medicaid preferred drug list (PDL) on July 25, 2024. The Texas Health and Human Services Commission (HHSC) based the update on changes presented and recommended at the January and April 2024 Texas Drug Utilization Review Board meetings. Drug list decisions from both the January and April meetings are available to review.

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, non-preferred, or having neither designation. The PDL includes only drugs identified as either preferred or non-preferred.
    • Drugs that are neither designated as preferred nor non-preferred are available without prior authorization.
    • Drugs on the PDL 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 may not request prior authorizations.

The PDL Criteria Guide outlines the standards used to evaluate prior authorization requests for non-preferred drugs. HHSC will update 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 a client is enrolled in.

  • For clients enrolled 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. Prescribers should use the MCO Search to find each MCO’s prior authorization call center phone numbers.
  • 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) or submit the request online using the VDP Provider Portal.

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.
  • There is a free subscription drug information service called epocrates that 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 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

It is the prescribing provider’s responsibility to obtain prior authorization. Pharmacy staff will alert the prescribing provider to get prior authorization if approval has not been obtained when the prescription is presented to the pharmacy. 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. Dispensing an emergency supply offers the person an immediate dose of the medicine, but they must return to the pharmacy to 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.

Email vdp-formulary@hhsc.state.tx.us with comments or any questions.