[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283858-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-283858-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","pharmacy-faq-for-physicians","Pharmacy FAQ for Physicians","","Guidance explains how the Medicaid and CHIP formularies are determined and how they affect coverage for members. Texas Vendor Drug Program (TXVDP) Preferred Drug Lists define preferred versus non-preferred medications, while CHIP coverage has no preferred status. The Texas Drug Utilization Review (DUR) Board meets quarterly to recommend products and review criteria. The document also outlines how prior authorization works, when requests are denied, and where providers can access formulary and coverage information, including phone and fax contacts.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/pharmacy-faq-for-physicians/283858/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/pharmacy-faq-for-physicians/283858.png","ImageObject",442,249,{"name":42,"@type":43},"Aditya","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-31","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",13,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Who determines the Medicaid and CHIP formularies and how does that affect coverage?","Question",{"text":63,"@type":64},"Superior Medicaid and CHIP programs must follow formularies and clinical criteria determined by the Texas Vendor Drug Program (TXVDP). Medications listed on the formulary are covered; medications not listed are not covered.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What is the difference between preferred and non-preferred medications for Medicaid?",{"text":68,"@type":64},"Preferred medications are listed on the TXVDP Preferred Drug List and are considered covered, though some products may require prior authorization based on clinical criteria. Non-preferred medications are covered only through prior approval.",{"name":70,"@type":61,"acceptedAnswer":71},"What happens if a prior authorization request is denied?",{"text":72,"@type":64},"If Superior denies a prior authorization for a prescription drug, the member and requesting provider receive written notification describing the outcome, including member appeal rights. If denial is due to lack of medical necessity, a formal denial letter is sent to both the member and the provider.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283858,1790183162,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":30,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":22},962085564549,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","Who determines the formulary, how does it affect me and where can I find the formulary?  \nSuperior Medicaid (STAR, STAR+PLUS, STAR Health, STAR Kids) and Children’s Health Insurance Plan (CHIP) programs must adhere to the Medicaid and CHIP formularies and clinical criteria determined by the Texas Vendor Drug Program (TXVDP) . The Medicaid formulary includes a Preferred Drug List (PDL) . Medications on the Medicaid formulary (PDL) are described as preferred and non-preferred. Medications on the CHIP formulary do not have a status of preferred or non-preferred. If medications are listed on theformulary , Medicaid and CHIP formularies, they are covered, but if they are not listed , they are not covered.  \n• Preferred: Products are listed on the TXVDP PDL and are considered covered. Please note: some products may require review of clinical criteria through submission of a prior authorization in order to obtain approval.  \n• Non-preferred: Products are listed on the TXVDP PDL, however are only covered through prior approval.  \nMembers must try at least one preferred medication first.  \nThe Texas Drug Utilization Review (DUR) Board meets quarterly to recommend products for the TXVDP PDL and review medical/therapeutic criteria. Additional information about the Texas DUR Board can be found at [https://www.txvendordrug.com/resources/drug-utilization-review-board](https://www.txvendordrug.com/resources/drug-utilization-review-board).  \nAmbetter from Superior HealthPlan (Marketplace), and STAR+PLUS Medicaid-Medicare Plan (MMP) each follow their own formulary. These formularies are determined by the Centene Corporate Pharmacy and Therapeutic Committee, who utilize clinical and economic criteria to determine which medications to cover on each formulary.  \nNot all drugs are included on the various formularies. Each formulary is reviewed by independent physicians and pharmacists on Superior’s Pharmacy and Therapeutics Committee, similar to the Corporate P&T members, for any recommendations to state Drug Utilization Review (DUR) board or to Corporate P&T committees for their consideration. Please reference the table below for formularies and pharmacy resources for each product.  \nFormulary and Prior Authorization Information  \nProduct Forms/Phone/Fax  \nFormulary/Criteria  \n\n| Medicaid/CHIP:\u003Cbr>STAR\u003Cbr>STAR Health\u003Cbr>STAR Kids\u003Cbr>STAR+PLUS CHIP | • TXVDP Preferred Drug List found at:\u003Cbr>[www.TXVendorDrug.com/formulary/](www.TXVendorDrug.com/formulary/)[ ](www.TXVendorDrug.com/formulary/)[prior-authorization/preferred-drugs](prior-authorization/preferred-drugs)\u003Cbr>• PDL Clinical Criteria found at:\u003Cbr>[SuperiorHealthPlan.com/ClinicalPrio](SuperiorHealthPlan.com/ClinicalPrio)rAuth\u003Cbr>• Quantity Limits found at:\u003Cbr>[SuperiorHealthPlan.com/Pharmacy](SuperiorHealthPlan.com/Pharmacy) | Medicaid/CHIP Prior Authorization Request Forms\u003Cbr>found [at:](at: SuperiorHealthPlan.com/ProviderForms)[ ](at: SuperiorHealthPlan.com/ProviderForms)[SuperiorHealthPlan.com/ProviderForms](at: SuperiorHealthPlan.com/ProviderForms)\u003Cbr>[The Pharmacy Relations and Provider Help Desk:](The Pharmacy Relations and Provider Help Desk:)\u003Cbr>• Phone: 1-800-460-8988\u003Cbr>Pharmacy Relations and Pharmacy Services Prior Authorization and Coverage Determination Department:\u003Cbr>• Phone: 1-866-768-7147\u003Cbr>• Fax: 1-833-423-2523 |\n| --- | --- | --- |\n| MedicaidMedicare:\u003Cbr>STAR+PLUS MMP | • STAR+PLUS MMP Formulary found at:\u003Cbr>[mmp.SuperiorHealthPlan.com/m](mmp.SuperiorHealthPlan.com/m)[mp/prescription-drug-part-](mp/prescription-drug-part-)[d/formulary.html](d/formulary.html) | STAR+PLUS MMP Coverage Determination and Redetermination Form found at:\u003Cbr>[mmp.SuperiorHealthPlan.com/mmp/prescription-drug](mmp.SuperiorHealthPlan.com/mmp/prescription-drug)part-d/coverage-determinations-exceptions. html\u003Cbr>CVS Caremark Pharmacy Help Desk:\u003Cbr>• 1-888-865-6567\u003Cbr>Pharmacy Solutions Coverage Determination:\u003Cbr>• Phone: 1-800-867-6564\u003Cbr>• Fax: 1-877-941-0480 |\n\n\n| Marketplace:\u003Cbr>Ambetter | • Ambetter","cbCaii73zCHXETbm","https://ap.wps.com/l/cbCaii73zCHXETbm","pdf",173967,"English","# Formulary determination and coverage impact\n## Preferred drug list and coverage rules\n## Texas DUR Board process\n## Plan-specific formularies (Ambetter and STAR+PLUS MMP)\n# Formulary and prior authorization information\n## Product resources: forms, phone, and fax\n# Prior authorization overview\n## What prior authorization means\n## Clinical criteria requirements\n## Denial outcomes and appeal rights","[{\"question\":\"Who determines the Medicaid and CHIP formularies and how does that affect coverage?\",\"answer\":\"Superior Medicaid and CHIP programs must follow formularies and clinical criteria determined by the Texas Vendor Drug Program (TXVDP). Medications listed on the formulary are covered; medications not listed are not covered.\"},{\"question\":\"What is the difference between preferred and non-preferred medications for Medicaid?\",\"answer\":\"Preferred medications are listed on the TXVDP Preferred Drug List and are considered covered, though some products may require prior authorization based on clinical criteria. Non-preferred medications are covered only through prior approval.\"},{\"question\":\"What happens if a prior authorization request is denied?\",\"answer\":\"If Superior denies a prior authorization for a prescription drug, the member and requesting provider receive written notification describing the outcome, including member appeal rights. If denial is due to lack of medical necessity, a formal denial letter is sent to both the member and the provider.\"}]","Pharmacy FAQ for Physicians | PDF",1789620927]