What are my prescription drug benefits?
You can receive medically necessary prescriptions ordered by your doctor or specialist. These prescriptions must be part of the Texas Medicaid Vendor Drug Formulary. Some prescriptions require pre-authorization.
How do I get my medications?
Medicaid pays for most medicine your doctor says you need. Your doctor will write a prescription so you can take it to the drug store, or may be able to send the prescription for you.
What do I bring with me to the drug store?
When you go to the drug store, take your prescription, your Texas Children’s Health Plan member ID card, and your Your Texas Medicaid Benefits card.
How do I find a network drug store?
You may have your prescription filled at any drug store that accepts Texas Children’s Health Plan STAR Kids. If you need a list of drug stores that take Texas Children’s Health Plan STAR Kids, call Member Services at 1-800-659-5764 or visit our website at www.TexasChildrensHealthPlan.org and click on the Pharmacy Listing link under the STAR Kids Members’ section.
What if I go to a drug store not in the network?
If you go to a drug store not in the network, you may not get your prescription filled, or may have to pay for it yourself. For a list of participating pharmacies, call Member Services at 1-800-659-5764 or visit our website at www.TexasChildrensHealthPlan.org and click on the Pharmacy Listing link under the STAR Kids Members’ section.
What is a Drug Formulary?
The formulary is a list of drugs chosen by doctors and pharmacists on the basis of quality and therapeutic value. It is a guide for doctors to know which drugs are covered. It includes brand name drugs and generics.
Who decides what drugs are on the formulary?
Formulary drugs are picked by a group of doctors and pharmacists. Only drugs that are safe, effective, and affordable are picked to be on the list. The group also selects drugs based on therapeutic value, side effects, and costs as compared to like medicines.
Where can I go to find out what drugs are covered?
Your formulary is on the Navitus website at www.navitus.com. You can search for a certain drug. You can also browse through lists of drugs. Also included is information about which drug needs prior approval and/or have quantity limits. It does not list every covered drug. The coverage or tier for each drug product is noted.
Do some drugs ordered by my/my child’s doctor require prior approval?
Some drugs ordered by your doctor may require prior approval. Your doctor may request a prescription drug prior approval by faxing a drug prior approval form to 1-855-668-8553. Sometimes you may experience a delay in getting your prescription filled. This is because Texas Children’s Health Plan may have requested additional information from your doctor. Please remind your doctor when your medication requires a prior approval.
If a drug does not appear in the drug list, your doctor may request a review by the Pharmacist by faxing a drug prior approval form to 1-855-668-8553.
What if I also have Medicare?
Medicare covers prescription drugs that are administered in a physician’s office or hospital outpatient department, such as cancer medications, injectables like antibiotics, or eye care treatments. Medicare pays up to the limits of its coverage then Medicaid becomes the payer up to the limits of coverage.
How do I get my medications if I am in a Nursing Facility?
If you are in a Nursing facility, they will provide you with medications.
How do I file a complaint or an appeal for medications ordered by my doctor?
The doctor will work with Navitus to request an exception to the formulary if needed. You have the right to appeal if you do not get an exception.When you have a concern about a pharmacy benefit, claim, or other service, please call Texas Children’s Health Plan at 1-800-659-5764. If your issue or concern is not resolved, you have the right to file a written appeal.
Who do I call if I have problems getting my medications?
If you have problems getting your medications, call Member Services toll-free at 1-800-659-5764 for help.
What if I can’t get the medication my doctor ordered approved?
If your doctor cannot be reached to approve a prescription, you may be able to get a 3-day emergency supply of your medication.Call Texas Children’s Health Plan toll-free at 1-800-659-5764 for help with your medications and refills.
What if I need my medications delivered to me?
If you need your medication(s) delivered, call Member Services toll-free at 1-800-659-5764 for help.
What if I lose my medication(s)?
If you lose your medication(s), call Member Services toll-free at 1-800-659-5764 for help.
Emergency Prescription Supply
A 72-hour emergency supply of a prescribed drug must be provided when a medication is needed without delay and prior authorization (PA) is not available. This applies to all drugs requiring a prior authorization (PA), either because they are non-preferred drugs on the Preferred Drug List or because they are subject to clinical edits.
The 72-hour emergency supply should be dispensed any time a PA cannot be resolved within 24 hours for a medication on the Vendor Drug Program formulary that is appropriate for the member’s medical condition. If the prescribing provider cannot be reached or is unable to request a PA, the pharmacy should submit an emergency 72-hour prescription.
A pharmacy can dispense a product that is packaged in a dosage form that is fixed and unbreakable, e.g., an albuterol inhaler, as a 72-hour emergency supply.
For more information, please call Member Services toll-free at 1-800-659-5764.
Medicaid Lock-In Program
What is Medicaid Lock-In Program?
You may be put in the Lock-in Program if you do not follow Medicaid rules. It checks how you use Medicaid pharmacy services. Your Medicaid benefits remain the same. Changing to a different health plan will not change the Lock-In status.
To avoid being put in the Medicaid Lock-in Program:
Pick one drug store at one location to use all the time.
Be sure your main doctor, main dentist, or the specialists they refer you to are the only doctors that give you prescriptions.
Do not get the same type of medicine from different doctors.
To learn more call Member Services toll-free at 1-800-659-5764.