Beginning with prescriptions filled on March 1, 2012.

No, Superior is contracting with a separate company to manage and administer the pharmacy benefit, that is called a Pharmacy Benefit Manager, or PBM. Their contact number is listed below. Members can call their member services phone number to assist with questions.

For issues that occurred prior to 3/1, or traditional Medicaid, pharmacies can call VDP for assistance.

Superior HealthPlan has contracted with US Script as our Pharmacy Benefit Manager (PBM), who is responsible for:

• Superior’s network of pharmacies;

• Pharmacy hotline calls;

• Administration of the Medicaid and CHIP drug formulary for Superior Members;

• Prior authorization for out-patient scripts;

• Receipt and payment of pharmacy claims;

• Complaints from pharmacies.

March 1, 2012.

No; US Script will be the exclusive provider for pharmacy services for Superior members as of that date. The Vendor Drug Program will continue to provide pharmacy benefits for Medicaid clients served by traditional Medicaid.

US Script has contracted with 95% of the current Vendor Drug Program pharmacy providers in Texas. The US Script pharmacy network includes the national chain pharmacies (e.g. Walgreen’s, CVS, HEB, Wal-Mart, Target, and Randall’s), as well as a large number of independent pharmacies. US Script’s pharmacy network can be accessed online at: http://www.superiorhealthplan.com/for-members/find-a-doctor, or by calling Superior’s Member Services Department for assistance.

The existing Texas Medicaid and CHIP formularies currently utilized by the Vendor Drug Program will be adopted.

• Texas Vendor Drug Program Website: www.txvendordrug.com

• Vendor Drug Formulary search:http://www.txvendordrug.com/formulary/formulary-search.asp
  NEED TO VERIFY “FORMULARY PRODUCT DETAIL” EFFECTIVE DATE FOR APPLICABLE MEDICAID OR CHIP PROGRAM

• Medicaid and CHIP formularies and Medicaid Preferred Drug List (PDL) are available on smart phone and web at www.epocrates.com.

• Texas PDL/PA Criteria to be used for Superior Members:
  http://www.txvendordrug.com/formulary/PDLSearch.asp (e-version)
  http://www.txvendordrug.com/downloads/pdl/TXPDL_072711.pdf (PDF)

Superior HealthPlan’s Pharmacy Department include:

• Assistance with specialty medication services, to include prior authorization for applicable services;

• Medical necessity denials;

• Pharmacy quality improvement projects; and

• Retrospective Drug Utilization Review (DUR) interventions with providers.

US Script is responsible for receipt and processing of prior authorization requests for medications to be dispensed through a pharmacy that are on the formulary, but not found on the Medicaid Preferred Drug List (PDL) and other Medicaid or CHIP member medications requiring prior authorization based on Clinical review criteria.

Superior HealthPlan retains responsibility for Prior Authorization of medication not dispensed through a pharmacy. These medications are most often billed by physician offices using HCPCS-J-codes. Participating Speciality Pharmacies may also bill Superior Health Plan directly.

Insulin syringes are included on the Vendor Drug formulary/Preferred Drug List (they do not require preauthorization), and can be billed by a retail pharmacy to US Script.

Covered Durable Medical Equipment/Medical Supplies may be obtained through a Superior HealthPlan participating provider. Durable Medical Equipment with a purchase price of greater than $500 and any Durable Medical Equipment/Medical Supplies provided by a non-participating provider require prior authorization from the Superior HealthPlan’s Prior Authorization Department.

A pharmacy that supplies Durable Medical Equipment/Medical supplies not on the Vendor Drug Formulary must:

• Have a contract with Superior; and

• For Medicaid Members, be enrolled with Texas Medicaid through TMHP as a medical provider; and

• For pharmacies that do not have a contract with Superior, obtain prior authorization for all services provided; and

• For pharmacies contracted with Superior, obtain prior authorization for DME/supplies >$500; and

• Bill claims directly to Superior.

Submit the request to US Script by phone or fax to:

• US Script PA Requests Phone: 866-768-7147

• US Script PA Requests Fax: 877-865-0813

24 hours after request is made by physician.

Incomplete prior authorization requests will be denied, and further information will be required to complete the request.

Superior HealthPlan will be processing all appeals, Fair Hearings, and IRO’s. To request an appeal, Fair Hearing or Independent Review the Member or Member’s authorized representative may call or write Superior at:
Superior HealthPlan
Attn: Appeals Coordinator
2100 South IH-35, Ste. 202
Austin, Texas 78704
800-218-7453 Ext. 22168 (phone)
866-918-2266 (fax)

Applies to medications requiring prior authorizations when the Prescriber cannot be reached to request prior authorization, or the prior authorization request is pending. Pharmacies (at the discretion of the pharmacist) may provide a 3 day supply of medication for prescriptions requiring prior authorization.. Pharmacy should make all attempts to notify the Provider’s office to request approval for change to drug on PDL and/or PA request.

Exceptions to the rule:

• Pharmacist may deny the 72 hour supply if he/she determines the medication is inappropriate for the Patient (i.e. adverse reactions)

• When medications are NOT covered through the Vendor Drug Program formulary.

• When the prior authorization has been previously reviewed and denied.

Yes, US Script is contracted with SureScript to handle the e-prescribing processes.