PCHP is contracted with a Pharmacy Benefit Manager (PBM) to provide prescription drugs to our members. The PBM is Navitus Health Solutions LLC.
Prescription Drug Coverage
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.
Formulary Drugs: Medications are generally covered under the plan without requiring additional approval
Non-Formulary Drugs: Medications not listed in the formulary that typically require prior authorization are considered to be non-formulary. Some medications listed may have additional requirements or limitations of coverage such as quantity limits, age limits, or step.
Clinical Edits: Clinical edits are rules set by the Texas Vendor Drug Program to ensure that medications are prescribed and used safely and appropriately. These edits may include limits on dosage, age restrictions, step therapy, or prior authorization requirements. They are based on clinical guidelines and help promote effective, evidence-based care for Medicaid members.
Texas Vendor Drug Program Clinical Edit Website
Prior Authorization Process
Approval needed before dispensing certain medications to ensure medical necessity.
View the Prior Authorization Form and send it to:
- Fax: 1-855-668-8553
- Mail: Navitus Health Solutions
Attn: Prior Authorization
1025 West Navitus Drive
Appleton, WI 54913
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.
Mail Order
You can assist a PCHP member in completing the Mail Order Form if you are prescribing a maintenance medication. Mail order is optional.
View the Mail Order Form.
72-Hour Emergency Fill
Federal and Texas law require pharmacies to dispense a 72-hour emergency supply of a prescribed drug when the medication is needed without delay and the prescriber is not available to complete the prior authorization. This applies to non-preferred drugs on the Preferred Drug List and any drug that is affected by a clinical prior authorization needing the prescriber’s prior approval. The pharmacy will submit an emergency 72-hour prescription when warranted; this procedure will not be used for routine and continuous overrides.
For further details on the 72-hour emergency supply requests, visit the Texas HHSC VDP website.
Member Copayments
Our members can get their prescriptions at no cost (STAR) or at low co-pays (CHIP) when:
- They get their prescriptions filled at an in-network pharmacy.
- Their prescriptions are on the preferred drug list (PDL) or formulary.
- View the CHIP copayments here
Claims Submission and Billing
BIN # 610602
Claim PCN; MCD
Rx Group # PCH
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.