The Texas Children's Health Plan Pharmacy Department gives pharmacy benefit services to our STAR and CHIP members. Our goal is to provide access to prescription medicine care to be sure that services are:
- A covered benefit.
- Medically necessary.
- Suitable to the patient's condition.
- Provided in the proper setting.
- Meet professional standards of pharmacy care.
Frequently Asked Questions (FAQs)
What are my prescription drug benefits?
Your prescription drugs are a benefit through your Texas STAR / CHIP coverage, as long as you go to a drug store in Texas Children's Health Plan network. There are some medicines that may not be covered through Medicaid / CHIP. A Texas Children's Health Plan network drug store can let you know which medicines are not covered, or help you and your doctor find another medicine that is covered. You can also ask your doctor or clinic about what medicines are covered, and what is best for you.
How do I get my child's medicines? Who do I call if I have problems getting my child's medicines?
Your Texas STAR / CHIP coverage pays for most medicines your doctor says you need. Your doctor will write a prescription so you can take it to the drug store. Or, your doctor may be able to send the prescription to the drug store for you. If you have trouble getting your medicines, please call Member Services at 1-866-959-6555 (CHIP) or 1-866-959-2555 (STAR).
How do I find a Texas Children's Health Plan network drug store? What do I bring with me to the drug store?
Texas Children's Health Plan provides prescription drugs for all its members through Navitus, which is the Texas Children's Health Plan pharmacy benefit manager (PBM). You can get your prescriptions filled at most drug stores in Texas. This list includes CVS, HEB, Kroger, Target, Walgreen's, Wal-Mart, and many other drug stores. If you need help finding a drug store, call Texas Children's Health Plan Member Services at 1-866-959-6555 (CHIP) or 1-866-959-2555 (STAR). A list of Texas Children's Health Plan network drug stores is also available here:
Remember: Always take your Texas Children's Health Plan ID card and your Texas Medicaid ID card with you to the doctor and to the drug store.
What if I go to a drug store that is not in the Texas Children's Health Plan network?
Texas Children's Health Plan has many contracted drug stores that can fill your medicines. It is important that you show your Texas Children's Health Plan ID card at the drug store. If the drug store tells you they do not take Texas Children's Health Plan members, you can call the Member Services Department at the numbers listed 1-866-959-6555 (CHIP) or 1-866-959-2555 (STAR). We can help you find a drug store that can fill your medicines for you.
What if I need my medicines delivered to me?
Texas Children's Health Plan also offers many medicines by mail. Some Texas Children's Health Plan network pharmacies offer home delivery services. Call Member Services 1-866-959-6555 (CHIP) or 1-866-959-2555 (STAR) to learn more about mail order or to find a pharmacy that may offer home delivery service in your area.
What if I lose my medicines?
If you lose your medicines, you should call your doctor or clinic for help. If your doctor or clinic is closed, the drug store where you got your medicine should be able to help you. You can also call TCHP's Member Services Department at 1-866-959-6555 (CHIP) or 1-866-959-2555 (STAR). We can help you get the medicines you need.
What if I can't get the medicines my child's doctor approved?
If your doctor cannot be reached to approve a prescription, you may be able to get a 3 day emergency supply of your medicine. Call Texas Children's Health Plan's Member Services at 1-866-959-6555 (CHIP) or 1-866-959-2555 (STAR) for help with your medicines and refills.
What is a pharmacy benefits manager (PBM)? Who is the PBM for Texas Children's Health Plan?
A PBM is a company that manages drug store benefits. Navitus is Texas Children's Health Plan's PBM. Navitus is responsible for:
- Texas Children's Health Plan's network of drug stores.
- Help with drug store claims through the Navitus Help Desk.
- Managing the Texas STAR and CHIP drug formulary, or list of medicines as prescribed by the Texas Vendor Drug Program (VDP).
- Prior approval for drugs not on the Texas VDP Preferred Drug List (PDL).
- Prior approval for Health and Human Services Commission specialty drugs listed in the Texas VDP.
- Managing clinical edits.
- Managing quantity limits.
- Provider requests for review of denied claims that were pre-approved..
- Coordination of benefits at a retail point-of-sale.
- Member requests for lost /stolen medicine concerns.
- Receipt and payment of drug store claims.
- Complaints from drug stores and reimbursement concerns.
How is the Texas Vendor Drug Program (VDP) used for Texas Children's Health Plan Medicaid members?
Navitus is the provider for drug store services for members. The Texas VDP maintains and publishes the Texas VDP Formulary and the associated PDL. It also maintains and publishes the clinical guidelines for drugs not on the PDL which require pre-approval, and are used by Navitus to give benefits for Texas Children's Health Plan STAR and CHIP members.
What drug stores does Navitus have contracts with?
Navitus has contracts with more than 95% of the VDP providers in Texas. The Navitus drug store network includes national chain drug stores such as Walgreen's, CVS, HEB, Wal-Mart, Target, and Kroger. And many others. Navitus' drug store network can be found here.
Contact Member Services at 1-866-959-6555 (CHIP) or 1-866-959-2555 (STAR) if you need help finding a drug store.
What formulary (list of medicines) will Navitus use?
Texas STAR and CHIP formularies are provided by the Texas VDP and are used for STAR and CHIP members. Information about the drugs on the Texas VDP Formulary and the associated PDL can be found here.
Where can I find the list of drugs that need pre-approval? Where do I find the Texas Children's Health Plan clinical edit criteria for pre-approval?
- The Texas Medicaid formulary is available on the Texas VDP website. The list is updated regularly and posted by the VDP at www.txvendordrug.com.
- The Texas Medicaid Prior Authorization Criteria is available at the Texas Vendor Drug Program website at https://www.txvendordrug.com/formulary/prior-authorization/mco-clinical-pa.
- Guidelines are created by the Texas VDP to determine if a patient is able to receive a certain medicine. These rules can be found here.
What is a clinical edit? How is it handled?
Clinical edits are rules that let us review a member's medical and drug claims history. The Texas VDP sets the criteria for clinical edits. If a patient does not meet the guidelines, then pre-approval will be required. If a patient does meet the guidelines, based on past medical and drug claims, the prescription will be approved without pre-approval.
What is a quantity limit? How is a quantity limit handled?
A quantity limit may lower the number (or amount) of drugs a patient can get during a certain time period. Quantity limits put a limit on the use of certain drugs for quality and safety reasons. The quantity limit for each drug is supported by the Food and Drug Administration (FDA) and by the instructions in the package insert. This program helps encourage the right drug use. If a quantity limit is given to a drug, and the prescription is higher than this quantity limit, the local pharmacist will make sure the request is safe. If the higher amount or dose of the drug is considered safe, a supply of up to 15 days will be given. The provider will contact Navitus to get approval for any request of the larger quantity.
What is step therapy? Are rules included for Texas Children's Health Plan Medicaid patients?
Step therapy is a program that ensures the most effective use of prescription drugs for patients. A step therapy plan starts with the most appropriate drug therapy based on national published guidelines. If those treatments do not work, other alternative treatments are considered.
How are generic substitutes handled?
The Texas VDP has a list of drugs on the PDL. A drug that is covered by this PDL may be brand or generic. The brand and its generic are normally not both covered. The generic substitution will not happen because only one drug will be covered by the Texas VDP PDL. Your doctor will look up your medicine on the Texas VDP PDL to make sure it is covered.
What is therapeutic interchange?
Therapeutic interchange is when drugs are prescribed that are chemically different, but therapeutically similar. Therapeutic interchange is used to control costs and should be approved by a prescriber. Texas Children's Health Plan will not deny coverage of any product covered under the Texas VDP. Texas Children's Health Plan may contact your provider to help you understand the Texas VDP formulary and all of the other options available for you. Any changes to your medicine should only be made with your doctor's consideration.
Who can issue prior authorizations for medicines?
Navitus is responsible for handling pre-approval requests for all drugs requiring prior authorization.