Who is the Pharmacy Benefit Manager (PBM) for Superior HealthPlan?
Superior HealthPlan has contracted with US Script as our Pharmacy Benefit Manager (PBM), who is responsible for:
- Superior’s network of pharmacies
- Pharmacy claim concerns via US Script Help Desk
- Administration of the Medicaid and CHIP drug formulary
- Administration of the Medicare formulary for Advantage Members via Argus claims processing platform
- Administration of the Ambetter formulary for Ambetter Members
- Prior authorization for non-preferred medications on the Vendor Drug Program
- Exception Requests for Medicare Part D medications for Advantage Members
- Prior Authorizations for Ambetter non-preferred medications
- Prior authorization for HHSC specialty drugs cross referenced to the Vendor Drug Program(exception Synagis which is worked at Superior)
- Administration of Clinical Edits
- Administration of Quantity Limits
- Provider request for Peer-to-Peer review of prior authorization denials
- Coordination of Benefits at retail point of sale
- Member requests for vacation or lost/stolen medication concerns
- Receipt and payment of pharmacy claims
- Complaints from pharmacies/pharmacy reimbursement concerns
When did the management of the prescription benefit change for Medicaid Members from the Vendor Drug Program to Superior? When did US Script begin processing Superior claims for Medicaid Members?
MCO organizations began overseeing the prescription benefits of their Medicaid Members on March 1, 2012. This is also the date US Script began processing the claims of these Superior Members. US Script is the PBM for Superior.
How is the Vendor Drug Program used for Superior Medicaid Members?
US Script is the exclusive Provider for pharmacy services for Superior Medicaid Members. The Vendor Drug Program will continue to provide pharmacy benefits for Medicaid Members served by traditional Medicaid. The Texas Vendor Drug program does supply the Texas Medicaid Preferred Drug List (PDL) and Clinical Edit criteria that are utilized by US Script to provide benefits for Superior Medicaid Members.
Do pharmacies and prescribers contact Superior for pharmacy questions about prior authorizations, clinical edits, quantity limits or regarding claims?
No. Superior is contracted with US Script, which is our PBM. A PBM is a company that manages and administers pharmacy benefits. Providers may call US Script to inquire about prior authorizations, clinical edits, quantity limits or to request a peer-to-peer review with a US Script Pharmacist. Pharmacies should refer to the US Script help desk for assistance with all non-Medicare claims. Pharmacies should refer to the Argus help desk for assistance with claims for Medicare.
How do I contact Argus as a pharmacist with a Medicare Advantage claim concern?
Argus will assist local pharmacy staff directly with questions regarding claims. Call 1-877-935-8021.
What pharmacies does US Script have contracts with?
US Script has contracted with more than 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. It is important to note that any pharmacy providing services for Superior Medicaid Members must be a Vendor Drug Program participant plus be contracted by US Script.
How is a Medicaid Member’s prescription processed if out-of-state?
Any pharmacy providing services for Superior Medicaid Members must be a Vendor Drug Program participant plus be contracted by US Script. If you are an out-of-state pharmacy Provider please contact the Texas Vendor Drug Program directly to become a VDP pharmacy Provider and also contact US Script to contract with our PBM.
What formulary 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. US Script uses the Ambetter formulary for Ambetter Members. US Script and its contracted claims processor (Argus) use the Medicare Advantage formulary for Advantage Members. All formularies are posted on our Superior HealthPlan website.
Where can I find the formulary and list of drugs requiring prior authorization? Where do I find Superior Medicaid Clinical Edit criteria?
- The Texas Medicaid Formulary is available via the Texas Vendor Drug Program Website. The formulary is regularly updated and posted by the VDP at www.txvendordrug.com
- The Texas Medicaid Prior Authorization Criteria is available via the Texas Vendor Drug Program website at http://www.txvendordrug.com/dur/Criteria.shtml
- A link to clinical criteria for non-preferred medications is available on the Superior web site at http://www.superiorhealthplan.com/for-providers/pharmacy/clinical-criteria-requirements/
- Clinical Edits are created by the Texas Vendor Drug Program. A direct link to all clinical edits currently used by Superior for Medicaid members is available at http://www.superiorhealthplan.com/for-providers/pharmacy/clinical-edits/
- The Ambetter Formulary is available at http://www.superiorhealthplan.com/for-providers/pharmacy/clinical-criteria-requirements/
- The Medicare Advantage Formulary is available at http://advantage.superiorhealthplan.com/home/prescription-drug-part-d-benefit-information/formulary/
What is a quantity limit? How is a quantity limit handled?
A quantity limit may reduce the number (or amount) of drugs covered within a certain time period. Quantity limits are designed to limit the use of selected drugs for quality and safety reasons. The quantity limit for each drug is supported by FDA-recommended use of the product and per approved dosing instruction in the package insert. This utilization management program encourages appropriate drug use. If a quantity limit is programmed for a medication and the prescription is outside of this predetermined quantity limit the local pharmacist will review the original request for safety. If the drug is deemed safe at this higher dose/quantity a supply of up to 15 days will be dispensed. The Provider should contact US Script to request a prior authorization approval for this dose to fulfill any balance request of the larger quantity per day supply.
What is step therapy? Are step therapy edits included for Medicaid patients?
Step therapy is an approach to prescription coverage intended to control the costs and risks posed by prescription drugs. A step therapy edit starts with the most cost-effective and safest drug therapy and progresses to other more costly or less safe therapies only if necessary. Currently, the Texas Vendor Drug Program 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 preferred medications on the Preferred Drug List (PDL). A drug that is covered under this PDL may be either brand or generic. Both the brand and its available generic generally are not both covered. Thus, generic substitution does not occur since only one product will be the covered entity. The prescriber is encouraged to reference the Vendor Drug Program when prescribing medication for the most up-to-date, covered medication entity.
What is Therapeutic Interchange?
Therapeutic interchange involves the dispensing of medications which are chemically different, but therapeutically similar in nature. Therapeutic interchange generally occurs for cost control and under the approval of a prescriber. We do not refuse coverage of any covered product under the Texas Vendor Drug Program in lieu of a similar covered product for cost control reasons. We may, however, contact the Provider to provide education on the Texas Vendor Drug Program formulary and all of the covered alternatives available for Members. Any changes to medication at any time should only be made under the Provider’s careful consideration.
What are the responsibilities of the Superior Pharmacy Department?
- Assistance with specialty medication services, to include prior authorization for HHSC specialty drugs cross-referenced to the Texas provider’s manual
- Synagis prior authorization requests
- Authorization request for Medicaid outpatient injectable medications (J Code Drugs)
- Authorization request for Ambetter outpatient injectable medications (J Code Drugs)
- Pharmacy quality improvement projects
- HEDIS measures involving pharmacy, measures to improve adherence
- Medicare adherence outreaches
- Assisting with recommendations for alternatives to high risk medications or HRMs
- Assisting offices, patients and pharmacies with gap in care concerns
- Retrospective Drug Utilization Review (DUR)
- Lock-in submission to Office of Inspector General (OIG)
How do I request a Medicare Part B Prior Authorization?
Requests for Medicare Part B Prior Authorization are handled by Superior’s Medicare Medical Management Department. Call 1-800-218-7508 or fax 1-877-808-9398.
Who will be responsible for issuing prior authorizations for medications?
US Script is responsible for receipt and processing of prior authorization requests for medications to be dispensed through a pharmacy that are non-preferred on the Medicaid Preferred Drug List (PDL). US Script is also responsible for processing all authorization requests for review of exceptions to clinical edits or quantity limits applied. US Script will also process prior authorization for exceptions to Part D Medicare prescriptions. Non-preferred products on the Ambetter formulary requiring prior authorization are also handled by US Script. 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. Superior HealthPlan Pharmacy Department is responsible for processing prior authorization of all HHSC specialty drugs cross-referenced to the Texas provider’s manual. The health plan pharmacy department also reviews all Synagis prior authorization requests. These medications are filled by our preferred specialty pharmacies: AcariaHealth or CVS/Caremark, except when there are cases of limited drug distribution.
How do I request Prior Authorization for Durable Medical Equipment/Medical Supplies?
The Texas Vendor Drug Program has a limited home health supplies list and many items such as insulin syringes and test strips are included in this coverage. The products are billed at a retail pharmacy via US Script, our PBM. A link to this information can be found at http://www.txvendordrug.com/formulary/limited-hhs.shtml. Covered Durable Medical Equipment/Medical Supplies may be obtained through a Superior HealthPlan participating Provider. To request a prior authorization from the Superior DME Prior Authorization Department please call 1-800-218-7508 ext. 53227.
How is a Medicaid COB edit (POS 41) occurring at point of sale?
COB is the coordination of benefits for members who have other coverage in addition to Medicaid. When eligibility files indicate a Member has other coverage and attempts to fill at retail, the POS 41 message ‘SUBMIT BILL TO OTHER PROCESSOR OR PRIMARY PAYOR’ will occur.
This message should be addressed at the local pharmacy by doing the following:
- Retail pharmacy will ask Member for the alternate insurance card, enter and process the claim under the other insurance.
- If Member does not have any other insurance or indicates this other coverage is no longer effective a retail pharmacy will contact the US Script Help Desk for an override for COB.
- After the override, the Member will be mailed a letter asking that the member please correct the eligibility status with the local Medicaid office.
- Member will contact Medicaid office directly to remove the other insurance from the account or COB edits may continue to fire.
How do I request Prior Authorization for drugs through US Script?
The following contact numbers to US Script are broken out by product. You may also contact US Script directly for turnaround concerns.
- 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
Medicare Part D:
All claims are processed by Argus. All prior authorizations are worked by US Script Pharmacists.
- US Script Medicare Exception Requests phone: 1-866-399-0928
- US Script Medicare Exception Requests fax: 1-877-941-0480
- US Script Ambetter PA Requests phone: 1-866-399-0928
- US Script Peer-to-Peer: 1-866-399-0928
- US Script Ambetter PA fax: 1-866-399-0929
What is the contact information for an appeal of a denied drug?
Attn: Appeals Coordinator
2100 South IH-35, Ste. 202
Austin, Texas 78704
Phone: 1-800-218-7453 ext. 22168
Superior Health Plan
Attn: Appeals Department
2100 South IH-35 Suite 200
Austin, TX 78704
Attn: Grievances & Appeals Medicare Operations
7700 Forsyth Blvd
Saint Louis, MO 63105
What is the 72-hour emergency prescription override?
This 72-hour emergency override applies to Medicaid Members who require prior authorizations when the prescriber cannot be reached or the request is pending. Pharmacies (at the discretion of the local pharmacist) may provide a 3-day supply of medication for prescriptions requiring prior authorization. The local pharmacy should make all attempts to notify the Provider’s office to request prior authorization or for a change to a preferred drug on the PDL. Any pharmacy needing assistance obtaining the 72-hour emergency supply override should contact the US Script Help Desk at 1-877-285-8489.
- Local pharmacists may deny the 72-hour supply if the medication is determined to be inappropriatefor 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?
Yes, US Script is contracted with SureScript to handle the e-prescribing processes.
HELPFUL CONTACTS AND INFORMATION
US SCRIPT, INC./Argus
- US Script Pharmacy Resolution Help Desk (non-Medicare): Call 1-877-285-8489
- Argus Pharmacy Resolution Help Desk (Medicare): 1-877-935-8021
- Rx Direct (Mail Order Service): 1-800-785-4197
SUPERIOR PHARMACY DEPT
- Medicaid/CHIP pharmacy concerns phone: 1-800-218-7453 ext. 22080
- Medicare, Foster Care & STAR+PLUS pharmacy concerns phone: 1-800-218-7453 ext. 22272
- Ambetter pharmacy concerns phone: 1-800-218-7453 ext. 22272
- Pharmacy Department fax for all programs: 1-866-683-5631