It’s important to Superior HealthPlan that our members get the right prescription drug coverage and drug therapy. We work hard to ensure you have access to safe and effective medications that are medically proven to help you get well and stay well.
What are my prescription drug benefits?
You get unlimited prescriptions through your Medicaid or CHIP coverage if you go to a pharmacy in Superior’s network. There are some medications that may not be covered through Medicaid or CHIP. A pharmacy in the Superior network can let you know which medications are not covered. The pharmacy can also 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.
What formulary (list of medicines) will Superior use?
Texas Medicaid and CHIP formularies are provided by the Texas Vendor Drug Program. Superior is required to implement this formulary list for all Medicaid and CHIP members. All formularies are posted here. Each Managed Care Organization (health plan) in Texas uses the same formulary list provided by the state.
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. Your doctor also may be able to send the prescription to the drug store for you.
If you have trouble getting your medicines, please call Superior Member Services.
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. You can get your prescriptions filled at most drug stores in Texas. These include CVS, HEB, Randall’s, Target and Walgreens, as well as many other pharmacies. If you need help finding a drug store, call Superior Member Services. A list of pharmacies in the Superior network is also available with Superior’s Find a Doctor tool.
Remember: Always take your Superior Member 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 Superior network?
Superior has many contracted drug stores that can fill your medications. It is important that you show your Superior Member ID card at the drug store. If the drug store tells you they do not take Superior members, you can call Superior Member Services for Medicaid or CHIP. 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 offers many medications by mail. Some Superior pharmacies offer home delivery services. Call Superior 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?
It is important to keep your medications in a safe and secure place. If you lose your medications please go to your local pharmacy. The pharmacy will work with Superior and our contracted Pharmacy Benefit Manager (PBM) to help in the review of a replacement.
What if I can't get the medication my child's doctor prescribed because it needs a prior authorization?
If your doctor cannot be reached to submit a prior authorization, you may be able to get a three-day emergency supply of your medication. Call Superior Member Services for Medicaid or CHIP 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).
What is a Pharmacy Benefit Manager (PBM)?
A PBM is a company that manages drug store benefits and the processing of drug claims. Superior HealthPlan uses a contracted PBM vendor. This vendor is responsible for:
- Superior’s network of drug stores.
- Pharmacy claim 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 Texas Health and Human Services Commission (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 clinical discussion of prior authorization denials.
- Coordination of benefits at retail point-of-sale.
- Receipt and payment of drug store claims.
- Complaints from drug stores for reimbursement concerns.
What drug stores does Superior HealthPlan have contracts with?
Our Pharmacy Benefit Manager (PBM) maintains our pharmacy network. We are contracted with more than 95% of the Vendor Drug Program providers in Texas. The drug store network includes the national chain pharmacies (e.g. Walgreen’s, CVS, HEB, Target and Randall’s), as well as many others. The drug store network can be found here or by calling Superior Member Services. Any drug store that gives services to Superior Medicaid/CHIP members must be a Vendor Drug Program participant and have a contract with our PBM. Contact Member Services at 1-800-783-5986 if you need help finding a pharmacy.
How is a Medicaid/CHIP 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. They should also call to contract with Superior’s Pharmacy Benefit Manager (PBM).
Where can I find the list of drugs that need prior authorization? Where do I find Superior Medicaid clinical edit criteria?
The Texas Medicaid formulary is available on the Texas Vendor Drug Program (VDP) website. The list is updated regularly and posted by the VDP.
The Texas Medicaid Prior Authorization Criteria is available at the Texas Vendor Drug Program website.
Clinical prior authorization edits are created by the Texas Vendor Drug Program. All clinical edits implemented by Superior HealthPlan can be found here.
What are the responsibilities of the Superior Pharmacy Department?
The Superior Pharmacy Department is responsible for:
- Assisting with specialty medication services. This includes prior authorization for Texas Health and Human Services Commission (HHSC) specialty drugs that are not part of the VDP formulary.
- Synagis prior authorization requests.
- Prior authorization requests for Medicaid outpatient injectable medications.
- Drug store quality improvement projects.
- Health Effectiveness Data Information Set (HEDIS) measures.
- Assisting with finding another option for high-risk medications (HRMs).
- Assisting offices, patients and drug stores with concerns about gaps in care or adherence.
- Retrospective Drug Utilization Review (DUR).
- Lock-in submission to the Office of Inspector General (OIG).
What is a clinical prior authorization edit and how is it handled?
Clinical prior authorization edits allow us to review a Medicaid/CHIP member’s medical and drug claims history. The Vendor Drug Program (VDP) sets the criteria for clinical prior authorization 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/or by the instructions in the package insert. This program encourages safe and appropriate 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 fifteen (15) days may be given. The provider will contact the Pharmacy Benefit Manager (PBM) vendor to request approval for 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 and CHIP members. Step therapy edits are not part of the Texas Vendor Drug Program at this time. However, the VDP may write steps into clinical prior authorization edits as appropriate.
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 provider is asked to look at the Vendor Drug Program website when prescribing medication and write for the preferred product.
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 preferred by the Texas Vendor Drug Program. Superior may contact your provider to review 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?
The Pharmacy Benefit Manager (PBM) vendor handles prior authorization requests for drugs that are non-preferred on the Medicaid Preferred Drug List (PDL). The PBM also handles all prior authorization requests for review of exceptions to clinical prior authorization edits or quantity limits.
Superior HealthPlan is responsible for prior authorization of drugs not usually given to you by a drug store. This includes certain specialty medications and injectable drugs provided in an outpatient setting. The Superior Pharmacy Department also reviews all Synagis and Makena prior authorization requests.
How do I request prior authorization for Durable Medical Equipment or 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 those at a local network pharmacy with a prescription. You may also get covered Durable Medical Equipment (DME) or 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.
What is the contact information for an appeal of a denied drug?
Attn: Appeals Coordinator
5900 E. Ben White Blvd.
Austin, Texas 78741
Phone: 1-800-218-7453, ext. 22168
What is the 72-hour emergency prescription override?
This is for Medicaid and CHIP 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 or safe for the member.
- When medications are NOT covered through the Vendor Drug Program formulary.
- When the prior authorization has been reviewed and previously denied.
- 72 hour supplies for Hepatitis C medications will not be approved.
SUPERIOR PHARMACY DEPARTMENT
- Medicaid/CHIP phone: 1-800-218-7453, ext. 22080.
- Foster Care, Medicare & STAR+PLUS phone: 1-800-218-7453, ext. 22272.