What Pharmacy Details Are You Missing?
Date: 07/05/16
Superior adheres to program-specific formularies and clinical criteria for our members. For Medicaid and CHIP programs, the preferred drug list (PDL) and clinical criteria are determined by the Texas Vendor Drug Program (TXVDP). Superior’s Medicare Advantage (HMO SNP), STAR+PLUS Medicare-Medicaid Plan (MMP) and Ambetter plans follow their own formulary and criteria. Some products listed on formularies may require prior authorization to make sure the medication is the most cost-effective way to provide quality care to our members.
Please reference the table below for 2016 formularies and prior authorization information.
| Plan | Formulary | Prior Authorization Form/Phone/Fax |
|---|---|---|
| Medicaid/CHIP | Non-Preferred Prior Authorization Form Phone: 1-866-399-0928, Option 1 Fax: 1-866-399-2929 | |
| Medicare Advantage (HMO SNP) (Medicare only) | 2016 Formulary (List of Covered Drugs) | Coverage Determination Request Form Phone: 1-866-399-0928, Option 2 Fax: 1-877-941-0480 |
| STAR+PLUS MMP (Medicare-Medicaid) | 2016 Formulary (List of Covered Drugs) | Coverage Determination Request Form Phone: 1-866-399-0928, Option 2 Fax: 1-877-941-0480 |
| Ambetter (Marketplace) | 2016 Formulary (List of Covered Drugs) | Prior Authorization Request Forms for Specialty Drugs Phone: 1-866-399-0928, Option 3 Fax: 1-866-399-0929 |
Clinical Criteria
The clinical criteria set by TXVDP is based on FDA-approved product labeling, national guidelines and peer-reviewed literature established by Texas Health and Human Services. All state managed care health plans are required to implement anti-psychotic, hepatitis C, Orkambi, and promethazine utilization for patients under the age of two. For more information, visit Superior’s clinical criteria requirements page.
Preferred Drug List (PDL)
The PDL is comprised of medications that have been reviewed for their effectiveness, clinical significance, cost effectiveness and safety for members.
- Preferred products are considered covered by Medicaid and CHIP, but may require submission of prior authorization to review clinical criteria to obtain approval (for example, Abilify, hydrocodone-APAP, montelukast, etc).
- Non-preferred products are only covered through prior approval from Medicaid and CHIP. Preferred and non-preferred products are listed on the TXVDP PDL.
- Not a covered benefit (NCB) products are not on TXVDP PDL and are considered excluded benefits. Per TXVDP, prior authorizations are not available and peer-to-peer (P2P) appeal rights are not applicable for NCB products; fair hearings are allowed.
The Texas Drug Utilization Review Board (DUR) meets quarterly to review medical/therapeutic criteria and recommend products for the PDL. Additional PDL information and DUR recommendations are highlighted in the Texas Medicaid and Healthcare Partnership (TMHP) article, April 2016 Drug Utilization Review Board Recommendation Available.
Peer-to-Peer Review and Appeals
When a prior authorization is denied, providers may conduct a P2P review or file an appeal if new and pertinent clinical information is provided. P2P reviews are conducted over the phone with a clinician and decisions are rendered immediately. Appeal requests on P2P decisions must be submitted in writing and a final determination is made by a medical director within thirty (30) days. For questions, or more information on P2P reviews and appeals, please contact one of the departments listed below.
Peer-to-Peer Review and Appeals Contacts
| Department | Phone Number |
|---|---|
| P2P | 1-866-399-0928, Option 4 |
| P2P for Behavioral Medications | 1-866-349-5794 |
| Appeals | 1-877-398-9461 |
For additional pharmacy information or questions, please contact Superior’s Pharmacy Department by phone at 1-800-218-7453, or by fax at 1-866-683-5631.