Pharmacy

What are my prescription drug benefits?

You get unlimited prescriptions through your Medicaid/CHIP coverage if you go to a pharmacy in Superior’s network. There are some medications that may not be covered through Medicaid/CHIP. A Superior pharmacy can let you know which medications are not covered, or help you find another medication that is covered. You can also ask your doctor or clinic about what medications are covered, and what is best for you.

How do I get my child's medications? Who do I call if I have problems getting my child's medications?

Medicaid/CHIP pays for most medicines 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 to the drug store for you.

If you have trouble getting your medicines, please call Member Services at the numbers listed on this website for your Medicaid or CHIP Program.

How do I find a network drug store? What do I bring with me to the drug store?

Superior provides prescriptions for all its members through US Script. You can get your prescriptions filled at most drug stores in Texas, including CVS, HEB, Randall’s, Target, Walgreens, Wal-Mart, as well as many other pharmacies. If you need help finding a drug store, call Superior Member Services at the numbers listed on this website for your Medicaid or CHIP Program.
A list of Superior pharmacies is also available online at http://www.superiorhealthplan.com/for-members/find-a-doctor/.

Remember: Always take your Superior ID card and your Medicaid ID card with you to the doctor and to the drug store.

What if I go to a drug store not in the network?

Superior has many contracted drug stores that can fill your medications. It is important that you show your Superior ID card at the drug store. If the drug store tells you they do not take Superior members, you can call Superior’s Member Services Department at the numbers listed on this website for your Medicaid or CHIP Program. We can help you find a drug store that can fill your medications for you.

If you choose to have the drug store fill your medications and they do not take Superior members, you will have to pay for the medication.

What if I need my medications delivered to me?

Superior also offers many medications by mail. Some Superior pharmacies offer home delivery services. Call Member Services to learn more about mail order or to find a pharmacy that may offer home delivery service in your area.

What if I lose my medications?

If you lose your medications, you should call your doctor or clinic for help. If your doctor or clinic is closed, the drug store where you got your medication should be able to help you. You can also call Superior’s Member Services Department at the numbers listed on this website for your Medicaid or CHIP Program, and we can help you get the medications you need.

What if I can't get the medication my child's doctor approved?

If your doctor cannot be reached to approve a prescription, you may be able to get a three-day emergency supply of your medication. Call Superior Member Services at the numbers listed on this website for your Medicaid or CHIP Program for help with your medications and refills.

What if I also have Medicare?

If you have Medicare and Medicaid (you are Dual Eligible), your prescription drug coverage changed on January 1, 2006. Instead of Medicaid paying for your prescriptions, they are now paid by a Medicare Rx plan. Under Medicare Rx, you have choices. Make sure the Medicare Rx plan you are with meets your needs. If you have questions or want to change plans you can call 1-800-633-4227 (1-800-MEDICARE).

Remember under Medicare Rx:

  • You have a choice of prescription drug plans.
  • All plans require you to pay $1 to $5 for each prescription.
  • There’s no limit on the number of prescriptions you can fill each month.

What if I have Ambetter (Health Insurance Marketplace)?

Ambetter Members please click here for information about your prescription drug benefits.

What is a Pharmacy Benefit Manager (PBM)? Who is the (PBM) for Superior HealthPlan?

A PBM is a company that manages drug store benefits. US Script is now Superior HealthPlan’s PBM. US Script is responsible for:

  • Superior’s network of drug stores.
  • Pharmacy claim concerns through US Script Help Desk.
  • Managing the Medicaid and CHIP drug formulary, or list of medicines.
  • Prior authorization for drugs not on the Preferred Drug List (PDL).
  • Prior authorization for HHSC specialty drugs listed in the Vendor Drug Program (This does not include Synagis, which is handled at Superior).
  • Managing clinical edits.
  • Managing quantity limits.
  • Provider requests for review of prior authorization denials.
  • Coordination of benefits at retail point-of-sale.
  • Member requests for lost/stolen medication concerns.
  • Receipt and payment of drug store claims.
  • Complaints from drug stores and reimbursement concerns.

When did the management of Member prescription benefits change from the Vendor Drug Program to Superior? When did US Script start processing Superior claims for Medicaid Members?

Superior began handling the prescription benefits of Medicaid Members on March 1, 2012. This is also the date US Script began handling claims from Superior Members.

How is the Vendor Drug Program used for Superior Medicaid Members?

US Script is the Provider for drug store services for Superior Medicaid Members. The Vendor Drug Program will continue to provide drug store benefits for Medicaid Members who have traditional Medicaid. The Texas Vendor Drug Program supplies the Medicaid Preferred Drug List (PDL) and clinical edits used by US Script to give benefits for Superior Medicaid Members.

What drug stores does US Script have contracts with?

US Script has contracts with more than 95% of the Vendor Drug Program Providers in Texas. The US Script drug store network includes the national chain pharmacies (e.g. Walgreen’s, CVS, HEB, Wal-Mart, Target, and Randall’s), as well as many others. US Script’s drug store network can be found at http://www.superiorhealthplan.com/for-members/find-a-doctor, or by calling Superior’s Member Services Department. Any drug store that gives services to Superior Medicaid Members must be a Vendor Drug Program participant and have a contract with US Script. Contact Member Services at 1-877-935-8023 if you need help finding a pharmacy.

How is a Medicaid Member’s prescription processed if out-of-state?

Out-of-state drug store Providers should contact the Texas Vendor Drug Program to become a VDP drug store Provider and also contact US Script to contract with Superior’s PBM.

What formulary (list of medicines) will US Script use?

Texas Medicaid and CHIP formularies are provided by the Texas Vendor Drug Program and are used for Medicaid and CHIP Members. All formularies are posted on Superior’s website.

Where can I find the list of drugs that need prior authorization? Where do I find Superior Medicaid clinical edit criteria?

What are the responsibilities of the Superior Pharmacy Department?

  • Assisting with specialty medication services. This includes prior authorization for HHSC specialty drugs that are in the Texas Provider’s manual.
  • Synagis prior authorization requests.
  • Prior authorization requests for Medicaid outpatient injectable medications.
  • Drug store quality improvement projects.
  • HEDIS measures.
  • Assisting with finding another option for high-risk medications (HRMs).
  • Assisting offices, patients and drug stores with concerns about gaps in care.
  • Retrospective Drug Utilization Review (DUR).
  • Lock-in submission to Office of Inspector General (OIG).

What is a clinical edit? How is a clinical edit handled?

Clinical prior authorization edits allow us to review a Medicaid Members’ medical and drug claims history. HHSC sets the criteria for clinical edits. If a patient does not meet the criteria then prior authorization will be required. If a patient does meet the criteria based on past medical and drug claims then the prescription will be approved without prior authorization.

What is a quantity limit? How is a quantity limit handled?

A quantity limit may lower the number (or amount) of drugs covered during a certain time period. Quantity limits put a limit on the use of certain drugs for quality and safety reasons. The quantity limit for each drug is supported by the Food and Drug Administration (FDA) and by the instructions in the package insert. This program wants to encourage the right drug use. If a quantity limit is given to a drug, and the prescription is higher than this quantity limit, the local pharmacist will make sure the request is safe. If the higher quantity or dose of the drug is considered safe, a supply of up to 15 days will be given. The Provider will contact US Script to get approval for any request of the larger quantity.

What is step therapy? Are step therapy edits included for Medicaid patients?

Step therapy is a program that helps control the costs of taking prescription drugs. A step therapy plan starts with the most cost-effective and safest drug therapy and moves to other more expensive or less safe therapies if necessary. Currently, the Texas Vendor Drug Program Preferred Drug List (PDL) is enforced for Medicaid Members. Step therapy edits are not part of the Texas Vendor Drug Program at this time.

How is generic substitution handled?

The Texas Vendor Drug Program has a list of drugs on the Preferred Drug List (PDL). A drug that is covered by this PDL may be brand or generic. The brand and its generic are not both normally covered. The generic substitution will not happen because only one drug will be covered. The Provider is asked to look at the Vendor Drug Program when prescribing medication.

What is therapeutic interchange?

Therapeutic interchange is when drugs are prescribed that are chemically different, but therapeutically similar. Therapeutic interchange is used to control costs and should be approved by a prescriber. Superior will not deny coverage of any product covered under the Texas Vendor Drug Program. Superior may contact your Provider to help you understand the Texas Vendor Drug Program formulary and all of the alternatives available for you. Any changes to your medication should only be made with your Provider’s consideration.

Who can issue prior authorizations for medications?

US Script is responsible for handling prior authorization requests for drugs that are not on the Medicaid Preferred Drug List (PDL). US Script is also responsible for handling all prior authorization requests for review of exceptions to clinical edits, age, gender or quantity limits.

Superior HealthPlan is responsible for prior authorization of drugs not usually given to you by a drug store. The Superior HealthPlan Pharmacy Department will handle prior authorization of some HHSC specialty drugs according to the Texas Provider’s manual. If the drug is on the HHSC specialty drug list and cross-referenced to the Vendor Drug Program (VDP), Superior will follow VDP guidelines. If prior authorization is needed per the Vendor Drug Program, US Script will process the request. If the drug is on the HHSC specialty drug list and cross-referenced to the Texas Provider’s manual and not the Vendor Drug Program, the Superior Pharmacy Department will process prior authorization requests.

The Superior Pharmacy Department also reviews all Synagis prior authorization requests. These medications are filled by Superior’s preferred specialty drug stores, AcariaHealth or CVS/Caremark except when drug distribution is limited.

How do I request prior authorization for Durable Medical Equipment/Medical Supplies?

The Texas Vendor Drug Program has a limited home health supplies list. That list includes many items like insulin syringes and test strips. You may get covered Durable Medical Equipment/Medical Supplies through a Superior HealthPlan Provider. To request a prior authorization from the Superior DME Prior Authorization Department, call 1-800-218-7508 ext. 53227.

How is a Medicaid COB edit (POS 41) occurring at point of sale?

Coordination of Benefits (COB) is for Members who have coverage in addition to Medicaid. When a Member has other coverage and tries to get prescriptions filled at retail, a POS 41 message will appear.

These steps should be taken if this message comes up:

  1. Retail pharmacy will ask Member for a different insurance card, enter and process the claim under the other insurance.
  2. If Member does not have any other insurance or says this other coverage is no longer effective a retail drug store will contact the US Script Help Desk for an override for COB.
  3. After the override, the Member will be mailed a letter asking that the Member please correct their eligibility status with the local Medicaid office.
  4. Member will contact the Medicaid office to remove the other insurance from the account.
  5. If the Member does not correct their eligibility status then the message will continue to appear each time a prescription is filled. It is important to follow step 4 if your eligibility with the other plan has changed.

How do I request prior authorization for drugs through US Script?

Here are the Medicaid contact numbers for US Script:

  • US Script CHIP/Medicaid PA requests phone: 1-866-399-0928.
  • US Script Peer-to-Peer: 1-866-399-0928.
  • US Script CHIP/Medicaid PA requests fax: 1-866-399-0929.

What is the contact information for an appeal of a denied drug?

Medicaid:
Superior HealthPlan
Attn: Appeals Coordinator
2100 South IH-35, Ste. 202
Austin, Texas 78704
Phone: 1-800-218-7453, ext. 22168
Fax: 1-866-918-2266

What is the 72 hour emergency prescription override?

This applies to Medicaid Members who need prior authorization when the prescriber cannot be reached or the request is pending. Drug stores may provide a 3-day supply of medication for prescriptions that need prior authorization. The local pharmacy should try to notify the Provider’s office to request prior authorization or for a change to a drug on the Preferred Drug List (PDL).

There are exceptions:

  • The local pharmacist may deny the 72-hour supply if he/she determines the medication is not appropriate for the Member.
  • When medications are NOT covered through the Vendor Drug Program formulary.
  • When the prior authorization has been reviewed and denied before.

Does US Script have the ability to help Providers online?

Yes. US Script has a contract with SureScript to handle prescription issues online. This is called e-prescribing.

HELPFUL CONTACTS AND INFORMATION

US SCRIPT, INC./Argus

  • US Script Pharmacy Resolution Help Desk (non-Medicare): 1-877-285-8489
  • Argus Pharmacy Resolution Help Desk (Medicare): 1-877-935-8021
  • Rx Direct (Mail Order Service) Phone: 1-800-785-4197

SUPERIOR PHARMACY DEPARTMENT

  • Medicaid/CHIP phone: 1-800-218-7453, ext. 22080.
  • Foster Care & STAR+PLUS phone: 1-800-218-7453, ext. 22272.
  • Pharmacy Department fax for all programs: 1-866-683-5631