Texas Providers

Pharmacy information


Pharmacy information for providers, including contact information and formulary details, can be found on this page. CarelonRx* is the pharmacy benefits manager.

Medicaid and CHIP formulary and Medicaid preferred drug list (PDL)

Please refer to the Texas Medicaid formulary and PDL , available through the Texas HHS Vendor Drug Program (VDP) website .

Texas Vendor Drug Program clinical edits

These clinical prior authorizations apply to patients enrolled in traditional Medicaid. Texas Vendor Drug Program clinical edits can be accessed through the Texas HHS Vendor Drug Program (VDP) website .

Prior authorizations


Providers are encouraged to write prescriptions for preferred products as listed on the Texas Medicaid formulary and preferred drug list (PDL), available on the Texas HHS Vendor Drug Program (VDP) website .

If, for medical reasons, a member cannot use a preferred product, providers are required to contact the Pharmacy department at Wellpoint at 1-833-731-2162 to obtain prior authorization. CHIP members’ claims will not require PDL prior authorization.

Pharmacy department:


1-833-731-2162

Medications that require prior authorization may include:

  • Drugs listed as nonpreferred on the PDL or drugs that require clinical prior authorization
  • Select self-administered injectable products
  • Drugs that exceed certain cost and/or dosing limits. (For information on these limits, call the Wellpoint Pharmacy at 1-833-731-2162.)

Note: This list is not all-inclusive and is subject to change.

Pharmacy prior authorization submissions


Online pharmacy prior authorization can be found through CoverMyMeds

Pharmacy prior authorization fax:

1-844-474-3341
Available 24/7.

Pharmacy phone (at Wellpoint):

1-833-731-2162
Available 7 a.m. to 10 p.m.

Medical injectable/infusible drugs prior authorization fax:


Prior authorization fax:

1-844-512-8995
Available 24/7.

Medicare

All Wellpoint Medicare Advantage plans include coverage of Medicare Part D prescription drugs, as well as those covered under Medicare Part B.

Formulary for individual Medicare Advantage products:

Coming soon!

Medicare Part D Rx coverage determinations

Providers can send a request for a prescription coverage determination for a Medicare plan via electronic prior authorization (ePA) rather than fax or phone by submitting the request from one of the following ePA websites:

Wellpoint STAR+PLUS MMP (Medicare-Medicaid Plan)

Members have access to most national pharmacy chains and many independent retail pharmacies that are contracted with us. Members may obtain their medications at any network pharmacy.

Clinical pharmacy policies

Drug coverage policies are based on medical necessity considerations subject to applicable benefits. These policies assist with medical necessity coverage decisions, may include state-specific guidance regarding coverage and do not constitute medical advice. Benefit determination is based on the applicable contract language and/or state requirements.

These policies are not a guarantee of coverage. Contract language or state requirements will prevail when there are conflicts with any medication coverage policy. In all cases, Medicaid contracts or CMS requirements supersede policy criteria.

 
* CarelonRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Wellpoint.

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