Pharmacy Prior Authorizations (PA)

PCHP is contracted with Navitus Health Solutions LLC to administer pharmacy benefits for Medicaid (STAR), CHIP, and CHIP Perinate members. Members may obtain their medications at any in-network pharmacy unless Texas HHSC has placed the member in the Office of Inspector General (OIG) Lock-In Program.   

A prescriber can submit a Prior Authorization Form to Navitus via fax, phone, or mail. Completed forms can be sent to Navitus 24 hours a day, seven days a week.

Prescribers can also submit a prior authorization request over the phone by calling Navitus Customer Care and speaking with the Prior Authorization department between 8 am and 5 pm CST. After hours, providers will have the option to leave a voicemail.

• Mail: Navitus Health Solutions
  Attn: Prior Authorizations
  1025 West Navitus Dr. 
  Appleton, WI 54913
• Phone: 1-877-908-6023
• Fax:1-855-668-8553

Pharmacy Payor Information

BIN # 610602
Claim PCN: MCD
Rx Group # PCH

Pharmacy Prior Authorization Timelines

• For Medicaid and CHIP – Immediately, if the prescriber’s office calls Navitus Health Solutions at 1-877-908-6023.
• For all other Medicaid prior authorization requests – Navitus notifies the prescriber’s office no later than 24 hours after receipt.
• If Navitus cannot provide a response to the pharmacy prior authorization request for Medicaid within 24 hours after receipt or the prescriber is not available to make a prior authorization request because it is after the prescriber’s office hours and the dispensing pharmacist determines it is an emergency situation, PCHP and Navitus allows the pharmacy to dispense a 72-hour supply emergency supply at the discretion of the dispensing pharmacist.

Formulary

We adhere to the HHSC Formulary and Preferred Drug List (PDL) for Managed Medicaid. The Texas Managed Medicaid formulary, including the PDL and any clinical edits, is defined by the Texas Vendor Drug Program.

• Texas Medicaid STAR/CHIP Formulary
• Texas HHSC Vendor Drug Preferred Drug List (PDL)
• Texas HHSC Vendor Drug Formulary

Texas Vendor Drug Program Clinical Edit Website

Synagis

Synagis Traditional Season (Fall/Winter) Initial Request prior authorization forms are posted below. The Synagis PA forms may be used to request coverage for STAR or CHIP members for the health plans listed below. Synagis remains active on the Texas Medicaid STAR and CHIP Formularies year-round. View the Synagis PA Form here.

Member Copayments

Our members can get their prescriptions at no cost (STAR) or at low copayments (CHIP)

• They get their prescriptions filled at an in- network pharmacy.
• Their prescriptions are on the preferred drug list (PDL) or formulary.
• Navitus Texas Provider Hotline (Pharmacy): 1-877-908-6023

View the CHIP copayments here

Pharmacy Forms:

Direct Member Reimbursement Form

Non-Formulary Drug Coverage Form

Override Request Form

Mail Order Form

Exception to Coverage Request Form

For additional questions related to the formulary, preferred drug list, billing, prescription overrides, prior authorizations, quantity limit, or formulary exceptions, call Navitus at 1-877-908-6023.