PHARMACY SERVICES – PROVIDER INFORMATION

Prescriptions

Parkland HEALTHfirst, KIDSfirst and CHIP Perinate/Perinate Newborn cover prescription medications. Our members can get their prescriptions at no cost (Medicaid) or at low copays (CHIP) when:

• They get their prescriptions filled at a network pharmacy
• Their prescriptions are on the preferred drug list (PDL) or formulary.

It is important that you as the provider know about other prescriptions your patient is already taking. Also, ask them about non-prescription medicine or vitamin or herbal supplements they may be taking.

PCHP Pharmacy plan is administered by Navitus. The Navitus Texas Provider Hotline (Pharmacy) is 1-877-908-6023.

Preferred drug list

You can find out if a medication is on the preferred drug list. Many preferred drugs are available without prior authorization (PA). Check the list of covered drugs on our website.

The Texas Medicaid preferred drug list is now available on the Epocrates drug information system.

The service is free and provides instant access to information on the drugs covered by the Texas formulary on a Palm, Pocket PC handheld device or smart phone.

Formulary drug list

The Texas Drug Code Formulary http://www.txvendordrug.com/formulary/formulary-information.shtml) covers more than 32,000 line items of drugs including single source and multi source (generic) products. You can check to see if a medication is on the state’s formulary list. Remember before prescribing these medications to your patient that it may require prior authorization.

If you want to request a drug to be added to the formulary please contact PCHP. We will then forward the information to the Formulary department of the Vendor Drug Program. 

Over the counter drugs

PCHP also covers certain over-the-counter drugs if they are on the list. Some of these may have rules about whether they will be covered. If the rules for that drug are met, PCHP will cover the drug. Check the list of covered drugs.

All prescriptions must be filled at a network pharmacy. Prescriptions filled at other pharmacies will not be covered.

Mail order form for your members

You can assist your member in completing the mail order drug form if you are prescribing a maintenance medication. Mail order is optional.

Prescription drugs must be ordered by a licensed prescriber within the scope of the prescriber’s practice. Prescriptions should be written to allow generic substitution whenever possible and signatures on prescriptions must be legible in order for the prescription to be dispensed.

Generics

Generic bioequivalent medications represent a considerable cost savings to health care. Those products available generically will be covered with the generic equivalent only (if the generic equivalent is on the preferred drug list), unless the brand has been specifically authorized or as otherwise noted. Generic forms of medications will be substituted as they become available unless otherwise designated. PCHP may grant an exception to the generic substitution.

Obtaining Pharmacy Prior Authorization

Navitus receives and processes pharmacy prior authorizations for our contracted Texas Managed Medicaid MCO members. 

The formulary, prior authorization criteria, and the length of the prior authorization approval are determined by HHSC.

Information regarding the formulary and the specific prior authorization criteria can be found at the Vendor Drug Website, Epocrates, and Surescripts certified vendors for e-Prescribing.

Prescribers can access prior authorization forms online via www.navitus.com under the “Providers” section or have them faxed by Customer Care to the prescriber's office. Prescribers will need their NPI and State to access the portal.

Completed forms can be faxed 24/7 to Navitus at 920-735-5312. Prescribers can also call Navitus Customer Care at 877-908-6023 > prescriber option and speak with the Prior Authorization department between 8a-5p M-F Central Time to submit a PA request over the phone.

Decisions regarding prior authorizations will be made within 24 hours from the time Navitus receives the PA request

The provider will be notified by fax of the outcome or verbally if an approval can be established during a phone request.

Medications that require prior authorization will be undergo an automated review to determine if the criteria are met.

If the automated review determines that all the criteria are not met, the claim will be rejected and the pharmacy will receive a message indicating that the drug requires prior authorization.

When a Prior Authorization is required and the provider is not available to submit the PA request, pharmacies are to dispense a 72 hour supply subject to pharmacist professional judgment.

The following message will be returned to pharmacies on all electronically submitted claims that rejects because the prior authorization criteria have not been met:

“Prescriber should call our Member Services or pharmacist should submit 72 hour Emergency Rx if prescriber not available.”

Obtaining a 72 Hour Emergency Fill

Federal and Texas laws require pharmacies to dispense a 72-hour emergency supply of a prescribed drug when the medication is needed without delay and the prescriber is not available to complete the prior authorization.

Applies to non-preferred drugs on the Preferred Drug List and any drug that is affected by a clinical PA needing prescriber’s prior approval

The pharmacy will submit an emergency 72-hour prescription when warranted; this procedure will not be used for routine and continuous overrides.

For further details on the 72 hour emergency supply requests, please use this link to the State VDP website: http://www.txvendordrug.com/downloads/72_hr_emergency_prescriptions.pdf

Navitus supports E-Prescribing

• Navitus provides point of care information available through Surescripts
• Eligibility confirmation
• Daily updates to eligibility facilitator
• Medication history
• Formulary and PDL benefit confirmation
• Formulary “alternative” drug list
• Formulary lists will be updated no less frequently than weekly
• Navitus expects pharmacies to have ability to accept e-prescriptions and facilitate refills with prescribers

Pharmacy Coverage and DME

• Certain disposable Medical Supplies (DMS) will be payable under the pharmacy benefit.
• Some examples include: Compression Stockings, Ketostix, Aerochambers, Peak Flow Meters and Diabetes Testing Supplies
• Navitus will respond with a paid claim response if the DMS product is covered
• Submit claims for DMS in the same manner as a traditional pharmaceutical drug claim
• Many Durable Medical Equipment items (DME) are covered under the medical plan
• Pharmacies are encouraged to enter into a contract directly with PCHP for DME covered benefits

• Pharmacies may be required to be accredited for DME services to participate

Pharmacy reimbursement

Navitus will pay clean claims submitted electronically no later than 18 days after adjudication and paper claims will be paid within 21 days of being adjudicated.

The Navitus reimbursement payment cycle for Texas will be weekly. Navitus offers participating pharmacies the option of receiving payments via ACH vs. paper if they so choose. In order for participating pharmacies to receive ACH payments they must complete the Electronic Fund Transfer (EFT) form. They may request this form by contacting the Pharmacy Network team at (608) 729-1577 or via email at providerrelations@navitus.com. Once the form is completed and sent back to Navitus, please allow 14-21 business days for setup.

Remittance Advices

• Electronic remittances may be accessed through our secure FTP server.
• If you are interested in receiving electronic remits, complete the 835 Request Form at navitus.com > Providers > Pharmacies Login
• Fax the completed form to Navitus using the number on the form.
• Allow 21 business days for setup. Navitus does place test files on the FTP server to assure a smooth transition for your pharmacy(s).
• Navitus reserves the right to charge an additional fee to create an 835 file or create a CD.
• Claims denied through the online adjudication system do not appear on the Remittance Advice.

• All payees requesting electronic fund transfer (ACH) for reimbursement will be required to accept electronic 835 remittances.

Additional Information for Pharmacists and Medical Professionals

Click on the link below for more detailed information (requires Adobe Acrobat):

Provider Training