Do pharmacies and prescribers contact Superior for pharmacy questions about prior authorizations, clinical edits, quantity limits or regarding claims?
No, Superior is contracted with our Pharmacy Benefit Manager (PBM). A PBM is a company that manages and administers pharmacy benefits. Providers may call the PBM to inquire about prior authorizations, clinical edits, quantity limits or to request a peer-to-peer review with a PBM Pharmacist. Pharmacies should refer to the PBM Help Desk for assistance with claims. Superior utilizes one PBM for Medicaid and one PBM for Medicare claims adjudication.
What is the Pharmacy Benefit Manager (PBM) responsible for?
Superior HealthPlan has contracted with our Pharmacy Benefit Manager (PBM), who is responsible for:
- Superior’s network of pharmacies.
- Pharmacy claim concerns via the Help Desk.
- Administration of the Medicaid and CHIP drug formulary as specified by the Vendor Drug Program.
- Administration of the Medicare formulary for Advantage and MMP members.
- 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 Prior Authorization Edits.
- Administration of Quantity Limits.
- Provider request for peer-to-peer review of prior authorization denials. Please note for behavioral health drugs, we contract with Cenpatico to provide a behavioral health specialist for these peer-to-peer reviews.
- Coordination of benefits at retail point of sale.
- Receipt and payment of pharmacy claims.
- Complaints from pharmacies regarding reimbursement concerns.
How is the Vendor Drug Program used for Superior Medicaid members?
The Vendor Drug Program will continue to provide pharmacy benefits for Medicaid clients served by traditional Medicaid. The Texas Vendor Drug program does supply the Texas Medicaid Preferred Drug List (PDL) and Clinical Prior Authorization Edit criteria utilized by the PBM to provide benefits for Superior Medicaid members.
What pharmacies does Superior have contracts with?
Superior, via our PBM, has contracted with over 95% of the current Vendor Drug Program pharmacy providers in Texas. The pharmacy network includes the national chain pharmacies (e.g. Walgreens, CVS, HEB, Target, and Randalls), as well as a large number of independent pharmacies. The 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. It is important to note that any pharmacy providing services for Superior Medicaid members must be a Vendor Drug Program participant and be contracted by the PBM.
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 our PBM.
What formulary will be used for each program?
Texas Medicaid and CHIP formularies are provided by the Texas Vendor Drug Program and are used for Medicaid and CHIP members. The Ambetter from Superior HealthPlan formulary is used for Ambetter members. The Superior HealthPlan Medicare Advantage (HMO SNP) formulary is used for Advantage members. The STAR+PLUS Medicare-Medicaid Program (MMP) formulary is used for MMP 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. www.txvendordrug.com
- The Texas Medicaid Prior Authorization Criteria is available via the Texas Vendor Drug Program website: https://www.txvendordrug.com/resources/drug-utilization-review-board/drug-use-criteria
- Clinical Prior Authorization Edits are created by the Texas Vendor Drug Program. A direct link to all clinical prior authorization edits currently used by Superior for Medicaid members is available at: http://www.SuperiorHealthPlan.com/providers/resources/pharmacy/clinical-prior-authorization.html
- The Ambetter Formulary is available at this link: https://Ambetter.SuperiorHealthPlan.com/provider-resources/pharmacy.html
- The Medicare Advantage Formulary is available at this link: https://Advantage.SuperiorHealthPlan.com/prescription-drugs-formulary.html
- The MMP Formulary is available at this link: https://mmp.SuperiorHealthPlan.com/prescription-drug-part-d.html
What are the responsibilities of the Superior Pharmacy Department?
- Prior authorization of HHSC specialty drugs which are not part of the Vendor Drug Program Synagis and Makena 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 and measures to improve adherence.
- Adherence outreaches.
- Assisting with recommendations for alternatives to high risk medications or HRMs.
- Assisting offices, patients and pharmacies with gaps in care concerns.
- Retrospective Drug Utilization Review (DUR).
- Lock-in submission to the 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 at 1-800-218-7508 (phone) or 1-877-808-9398 (fax).
Who will be responsible for issuing prior authorizations for medications?
The contracted PBM will review prior authorization for non-preferred medications, any clinical prior authorization edits or other limitations for Medicaid, CHIP, Ambetter and Medicare.
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 not part of the VDP formulary. The health plan pharmacy department also reviews all Synagis and Makena prior authorization requests
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: https://www.txvendordrug.com/formulary/home-health-supplies.
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 do I request prior authorization for drugs?
The following contact numbers are broken out by product. You may also contact US Script directly for turn-around concerns.
Medicaid and CHIP
- CHIP/Medicaid PA Requests Phone: 1-866-399-0928
- Peer-to-Peer: 866-768-71471-866-399-0928
- 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.
- Medicare Exception Requests Phone: 1-866-399-0928
- Medicare Part DFax:Medicare Exception Requests Fax: 1-877-941-0480
Ambetter from Superior HealthPlan
- Ambetter PA Requests Phone: 1-866-399-0928
- Peer-to-Peer: 1-866-768-7147866-399-0928
- Ambetter PA Fax: 1-866-399-0929
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
Ambetter from Superior HealthPlan
Attn: Appeal Department
5900 E. Ben White Blvd.
Austin, Texas 78741
Attn: Grievances & Appeals Medicare Operations
7700 Forsyth Blvd
Saint Louis, MO 63105
Email: D-SNP Appeals and Grievances DSNPAPPEALSGRIEVANCES@superiorhealthplan.com
What is the 72-hour emergency prescription override?
The 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 Help Desk at 1-877-285-8489.
Exceptions to the rule:
- Local 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?
Yes, the PDM is contracted with SureScript to handle the e-prescribing processes.
Helpful contacts and information
- Medicare and MMP Pharmacy Resolution Help Desk: 1-877-935-8021
- Medicaid and Ambetter Pharmacy Resolution Help Desk: 1-866-399-0928
- Mail Order Service Phone: 1-800-785-4197
Superior Pharmacy Department
- Medicaid/CHIP Pharmacy concerns: 1-800-218-7453 ext. 22080
- Medicare, STAR Health (foster care), STAR Kids and STAR+PLUS Pharmacy concerns: 1-800-218-7453 ext. 22272
- Ambetter Pharmacy concerns: 1-800-218-7453 ext. 22080
- Pharmacy Department fax for all programs: 1-866-683-5631