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Third Party Resources - Pharmacy

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Welcome to the TMHP Third Party Resources (TPR) Pharmacy page. As a reminder, Medicaid is the payer of last resort, meaning that all other available pharmacy benefits must be used before Medicaid will provide payment. 

Documenting Other Insurance Coverage

To ensure accurate claims processing and compliance, it is essential to identify and document any additional pharmacy coverage that a Medicaid client may have. Properly coordinating benefits not only supports timely and accurate payment but also helps reduce unnecessary costs to Texas Medicaid.

Information Needed to Perform a TPR Update:    
•    Policyholder name, if available (first, last) 
•    Bank Identification Number (BIN)
•    Insurance pharmacy benefits manager name
•    Processor Control Number (PCN)
•    Group ID number
•    Policy subscriber ID
•    Person code
•    Effective date
•    Termination date 

72-Hour Emergency Supply

Pharmacies should provide a 72-hour emergency supply of a prescribed drug when a client needs the medication without delay, and prior authorization is unavailable. This applies to drugs that are non-preferred on the Preferred Drug List and drugs that are subject to clinical prior authorization. The emergency override protocol applies to clients who are enrolled in traditional Medicaid or Medicaid managed care.

Before dispensing a 72-hour emergency supply, the pharmacist should use professional judgment to determine if taking the prescribed medication will jeopardize the client's health or safety and make good-faith efforts to contact the prescribing provider.

A 72-hour emergency prescription will be reimbursed in full, and it does not count toward the three-prescription limit for adults who have not already received the maximum number of prescriptions for the month. Pharmacies should not use this procedure for routine and continuous overrides.