Provider Pharmacy Prior Authorization Forms are located on the Provider Resources Forms page, under Prior Authorization Forms.
Superior HealthPlan is committed to providing appropriate, high-quality and cost-effective drug therapy to all members. Superior covers prescription medications as outlined by the Texas Medicaid and CHIP Vendor Drug Program (VDP). Some medications may require prior authorization, and may have clinical prior authorization edits or other limitations consistent with FDA recommendation for safe and effective use. Other medically necessary pharmacy services or products are covered as well and consistent with the Vendor Drug Program.
Pharmacies wishing to be contracted as a provider are required to be a Medicaid provider and be contracted with Superior’s Pharmacy Benefit Manager (PBM). Pharmacies should contact the contracted PBM and the Vendor Drug Program directly for contracting assistance.
For prior authorization of medications covered by the VDP, contact the contracted PBM at 1-800-460-8988.
For information regarding contracting as a network pharmacy, please visit the Envolve Pharmacy website.
To access the Texas Medicaid/CHIP Vendor Drug Program (VDP), including the Medicaid formulary and Preferred Drug List (PDL), visit the Texas Vendor Drug website.
- Clinical Prior Authorization
- Clinical Prior Authorization Criteria Requirements
- CoverMyMeds: Prescription Drug Prior Authorization (PDF)
- Diabetic Meter Program (PDF) - Effective 1/30/17, True Metrix is the preferred brand for Medicaid and CHIP products.
- Medicaid Electronic Formulary and PDL
- Texas Vendor Drug Program Formulary and PDL
- Quantity Limits (PDF)
- Superior HealthPlan STAR+PLUS MMP List of Covered Drugs (Formulary)
- Prescription Monitoring Program (PMP) Reference Guide (PDF)
- Pharmacy Processing Information for Physicians (PDF)
- Pharmacy Processing Information for Pharmacies (PDF)
- Proton Pump Inhibitors (PPIs): Use and Risks in Adults (PDF)
- Proton Pump Inhibitors (PPIs): Use and Risks in Pediatrics (PDF)
- Superior HealthPlan's Opioid Toolkit
- TMF Network - Potentially Inappropriate Medications in Older Adults
- Allwell from Superior HealthPlan Formulary
- Medicare Part B Drug Prior Authorization Request Form (PDF)
- Medicare Part B List of Drugs Requiring Prior Authorization (PDF)
- Notification for Medicare Part B Medications (PDF)
- Prior Authorization Criteria
- Quantity Limit Listing
- Step Therapy Criteria
- Request for Medicare Coverage Determination Form
Medicaid/CHIP Pharmacy Help Desk
Toll Free: 1-866-768-0468
Prior Auth Requests
Medicare Pharmacy Help Desk
Toll Free: 1-877-935-8021
Prior Auth Requests
Clinician Administered Drugs
Phone: 1-800-218-7453 ext. 22272
Out-Patient Rx (PBM: Envolve Pharmacy Solutions)
Resolution Help Desk: 1-800-460-8988
Prior Auth Requests Phone: 1-866-399-0928
Prior Auth Requests Fax: 1-866-399-0929
Appeal Requests (Superior Prior Authorization Department)
Toll Free: 1-877-398-9461 ext. 22168