When does the management of the prescription benefit change from the Vendor Drug Program to Superior?
Do pharmacies and prescribers contact Superior for pharmacy questions and claims?
For issues that occurred prior to 3/1, or traditional Medicaid, pharmacies can call VDP for assistance.
Who is the Pharmacy Benefit Manager (PBM) for Superior HealthPlan?
- 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.
What is the effective date for US Script to begin paying Pharmacy Claims for Superior Members?
Will the Vendor Drug Program be utilized for Superior CHIP and Medicaid Member prescription fills after March 1, 2012?
What pharmacies does US Script have contracts with?
What Formulary will US Script use?
Where can I find the formulary and list of drugs requiring prior authorization?
- 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:
What are Superior HealthPlan’s Pharmacy Department responsibilities?
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.
Who will be responsible for issuing Prior Authorizations for medications?
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.
How do I request Prior Authorization for Durable Medical Equipment/Medical Supplies?
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.
How do I request Prior Authorization for drugs through US Script?
- US Script PA Requests Phone: 866-768-7147
- US Script PA Requests Fax: 877-865-0813
If Prior Authorization is required, what is US Script’s turnaround time for medication requests?
Incomplete prior authorization requests will be denied, and further information will be required to complete the request.
What is the process for appeal of a denied drug?
Attn: Appeals Coordinator
2100 South IH-35, Ste. 202
Austin, Texas 78704
800-218-7453 Ext. 22168 (phone)
What is the 72 hour emergency prescription override?
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.
Does US Script have E-prescribing capabilities?
HELPFUL CONTACTS AND INFORMATION
US SCRIPT, INC.
- Pharmacy Resolution Help Desk: 866-768-0468 (Most often used by pharmacies)
- PA Requests Phone: 866-768-7147
- PA Requests Fax: 877-865-0813
- Over the Counter Value added services (STAR/STAR+PLUS only) Phone: 866-768-8490
- Mail Order Phone: 800-785-4197
- Website: http://www.usscript.com/pharmacists-overview.php
SUPERIOR PRIOR AUTHORIZATION DEPT) – DME/ SUPPLIES
Preauthorization is required when the purchase price is greater than $500 and/or if the provider is not participating with Superior Health Plan.
- PA Requests Phone: 800-218-7508
- PA Requests Fax: 800-690-7030
Appeal (SUPERIOR Appeal DEPT)
- Appeal Requests Phone: 800-218-7453
- Appeal Requests Fax: 866-918-2266
SUPERIOR PHARMACY DEPT – SPECIALTY MEDICATIONS/PROBLEM RESOLUTION
- Phone: 877-391-5921
- Fax: 866-683-5631