Most Medicaid clients and all Children’s Health Insurance Program (CHIP) clients receive their prescription drug benefits through the managed care service delivery model.
- Pharmacy providers must be contracted with VDP before participating in any managed care network.
- The Pharmacy Enrollment Chart (PDF) identifies how pharmacy providers with questions pertaining to a new, pending, or existing can contact each health plan and pharmacy benefits manager (PBM).
- The MCO Service Area Chart (PDF) provides a breakout of which health plans serve each service delivery areas (SDA).
Managed Care Medical Plans
- Managed Care Plan Information
- The Pharmacy Assistance Chart (PDF) identifies the name and pharmacy billing information for each health plan and individual call center phone numbers.
- Expansion of Medicaid Managed Care
- Medicaid/CHIP MCO Notices
Clinical Prior Authorizations
- Certain clinical prior authorization criteria must be performed for Medicaid managed care clients. Health plans may implement any of the approved criteria but no more. Pharmacy staff should verify with each plan to identify which criteria apply.
Home Health Supplies
- Pharmacies must be enrolled with VDP and with the health plan’s pharmacy benefit manager (PBM) to provide the limited set of home health supplies to individuals enrolled in Medicaid managed care or the Children’s Health Insurance Program (CHIP). Pharmacy staff should contact the health plan in their service area to determine the billing requirements, reimbursements rates, and coverage limitations for these products.
- Authorization is required for non-preferred drugs and drugs subject to clinical criteria for Medicaid managed care clients.
- Call center phone numbers vary by health plan. The Prescriber Assistance Chart (PDF) identifies prior authorization and member call center phone numbers for each health plan.
- Each health plan must notify the prescribing physician’s office of authorization approval/denial within 24 hours of the time of the request.
Complaints & Appeals
- Pharmacy providers must exhaust the complaints or grievance process with the health plan before filing a complaint with HHSC.