Pharmacy Provider Training - Texas Managed Care Medicaid STAR and CHIP Programs - Question and Answers

Sep 17, 2026

Upload by Oliver

Pharmacy Provider Training materials for Texas Managed Care Medicaid STAR and CHIP Programs in a Q&A format address operational requirements and coverage workflows. Topics include how frequently price updates occur, how Navitus handles prior authorization submissions and electronic PAs, login and NPI/NCPDP requirements, preferred formulary lookup sources, and MAC update timing. Detailed guidance covers 72-hour emergency prescription procedures, override handling, and claim field expectations when prior authorization is not on file.

LanguageEnglish

CategoryLetters

FormatPDF

Pages5

Reading Time2 min

AccessFree to download

Question and Answers

Price updates and MAC pricing

Prior authorization and electronic processes

Formulary lookup and coverage rules

72-hour emergency prescription procedure

Pharmacy Provider Training Texas Managed Care Medicaid STAR and CHIP Programs Question and Answers How often are price increases updated in your system and is Navitus current with its price updates? Navitus subscribes to Medi-Span drug information reporting services and updates our systems weekly, typically every Tuesday. Are pharmacies allowed to obtain a login to the online portal to submit PAs electronically instead of paper PA forms? Navitus implements an electronic PA process for some clinical edits and for non-preferred medications via the Point of Sale. If the necessary information from the claim isn’t available or does not meet the criteria for an automatic approval, the PA forms are available on the Navitus website. All PA forms must be submitted by the patient’s physician via fax or phone. Are there NPI specific logins for each pharmacy? Each pharmacy must utilize their NPI/NCPDP number assigned to the actual pharmacy location. Which is the best formulary list to look up drugs that would be covered? All three referenced websites listed below provide accurate information on the formulary and can be used to access formulary information. 􀁸 HHSC Vendor Drug Website – [www.txvendordrug.com](www.txvendordrug.com) 􀁸 Epocrates – [www.epocrates.com](www.epocrates.com) 􀁸 [Navitus.com](Navitus.com) – [www.navitus.com](www.navitus.com) Are there any plans for updating MAC prices more often since the generic prices have significantly increased? Navitus reviews and updates its Maximum Allowable Cost (MAC) list of drugs and associated unit prices monthly. Navitus continually monitors our sources of drug acquisition prices. If an event occurs between MAC updates for a certain drug or drugs that significantly increases or decreases the acquisition cost of such drug, Navitus will adjust the MAC between updates. Can unit of use bottles be broken or may whole bottles be dispensed? This will depend on the specific product being dispensed. If there are questions on a specific NDC, please contact Navitus Texas Provider Hotline at 877-908-6023. Can a pharmacy call for a prior authorization if the unit of use exceeds the prescribed days’supply according to prescription? If not, then how does a pharmacy handle this issue? This would not require a prior authorization, but similar to the previous question, this may depend on the specific product being dispensed. If the unit of use exceeds the prescribed days’ supply according to the prescription for an unbreakable package (e. g. , cefdinir suspension is available in 60ml and 100ml bottles, but the prescription directions require 70ml), the pharmacy may call Navitus Texas Provider Hotline at 877-908-6023 for an override. Customer Service may need to reach out to a clinical pharmacist to verify the dosing or offer other dosing suggestions; however the override can be entered without a prior authorization. Could you explain the 72 hour procedure? If a Prior Authorization is required and not on file, a rejection message will be returned to the pharmacy indicating that the prescriber should contact Navitus. If the prescribing provider cannot be reached, or is unable to request a prior authorization, the pharmacy should move forward with submitting an emergency 72-hour prescription claim. Pharmacies are required to dispense a 72-hour emergency supply of prescription drugs for all drugs not on the preferred drug list if the denial is solely due to lack of prior authorization. If the medication is a dosage form that prevents a three-day supply from being dispensed ([e.g. an](e.g. an)[ ](e.g. an)inhaler, eye or ear drops, or creams) it is permissible to indicate that the emergency prescription is a three-day supply, and enter the full quantity dispensed. The requirement that the Member be given at least a 72-hour supply for a new medication does not apply when the dispensing pharmacist determines that the taking of the prescribed medication would jeopardiz

FAQs

How often are price increases updated in your system, and when does Navitus typically update price information?

Navitus subscribes to Medi-Span and updates systems weekly, typically every Tuesday. MAC is reviewed and updated monthly, with adjustments between updates if acquisition costs change significantly.

Can pharmacies obtain access to submit prior authorizations electronically instead of using paper forms?

Navitus implements an electronic PA process for certain clinical edits and non-preferred medications via the Point of Sale. If automatic approval criteria are not met, PA forms are available on the Navitus website, and all PA forms must be submitted by the patient’s physician via fax or phone.

What is the 72-hour procedure when a prior authorization is required but not on file?

A rejection message instructs the prescriber to contact Navitus. If the prescriber can’t be reached or can’t request a prior authorization, the pharmacy submits an emergency 72-hour prescription claim and must dispense a 72-hour emergency supply when denial is solely due to lack of prior authorization.

Sep 17, 2026

Upload by Oliver