Pharmacy FAQs

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 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. 
• Coordination of benefits at retail point of sale.
• Receipt and payment of pharmacy claims.
• Complaints from pharmacies regarding reimbursement concerns.

The Texas Vendor Drug program supplies the Texas Medicaid Preferred Drug List (PDL) and Clinical Prior Authorization Edit criteria utilized by the PBM to provide benefits for Superior Medicaid members.

Superior, via the PBM, has contracted with over 95% of the current Vendor Drug Program pharmacy providers in Texas. The pharmacy network includes national chain pharmacies (e.g. CVS, HEB, Target, and Randalls), as well as a large number of independent pharmacies. The pharmacy network can be accessed online at Superior's Find a Provider webpage, 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.

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. For Medicare beneficiaries, please visit one of the following:

• Wellcare: Wellcare.com/Texas
• Wellcare By Allwell: Wellcare.SuperiorHealthPlan.com
• Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP): MMP.SuperiorHealthPlan.com

• The Texas Medicaid Formulary is available via the Texas Vendor Drug Program website. The formulary is regularly updated and posted by the VDP.
• The Texas Medicaid Prior Authorization Criteria is available via the Texas Vendor Drug Program website.
• 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 Superior's Clinical Prior Authorization webpage. 
• The Ambetter from Superior HealthPlan's Formulary is available at Ambetter's Pharmacy webpage.

• 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 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).

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 prior authorization requests

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 the PBM.  A link to this information can be found at the Texas Vendor Drug Program website.

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. 

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 Phone: 1-866-399-0928
• CHIP/Medicaid PA Requests Fax: 1-833-423-2523

Ambetter from Superior HealthPlan

• Ambetter PA Requests Phone: 1-866-399-0928
• Peer-to-Peer Phone: 1-866-399-0928
• Ambetter PA Fax: 1-800-977-4170

Medicaid

Superior HealthPlan
Attn: Appeals Coordinator
5900 E. Ben White Blvd.
Austin, Texas 78741
Phone: 1-800-218-7453 Ext. 22168
Fax: 1-866-918-2266

Ambetter

Ambetter from Superior HealthPlan
Attn: Appeal Department
5900 E. Ben White Blvd.
Austin, Texas 78741
Phone: 1-877-687-1196
Fax: 1-800-716-2036

Medicare

Centene Corporation
Attn: Grievances & Appeals Medicare Operations
7700 Forsyth Blvd 
Saint Louis, MO 63105
Phone: 1-877-861-6724 
Fax: 1-844-273-2671

Email: D-SNP Appeals and Grievances DSNPAPPEALSGRIEVANCES@superiorhealthplan.com

The 72-hour emergency override applies to Medicaid/CHIP 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 PBM Help Desk at 1-866-399-0928.

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.
• Hepatitis C medications. 

Yes, the PBM is contracted with SureScript to handle the e-prescribing processes.

Medicaid/Medicare PBM

• 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

For more information, please visit our Medicare plans:

• Wellcare: Wellcare.com/Texas
• Wellcare By Allwell: Wellcare.SuperiorHealthPlan.com
• Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP): MMP.SuperiorHealthPlan.com