Texas Medicaid
What is the Copay for a STAR member?
What does P stand for on the formulary?
Preferred.
What are the two TP's we process for?
Alliance Health Plan and Vaya Health Plan.
Do we use the blue box in Launch House to verify out formulary information?
No. Must pull up the printed formulary for all Medicaid clients.
Can you switch out a drug if pharmacy is running claim with a DAW 1?
No. Substitution not allowed by provider.
What is the Day Supply allowed for a Texas Medicaid member?
34 Day Supply
What does EDS stand for on the formulary?
90 Day Supply allowed.
Are we allowed to process QL's at the same time as PA?
Yes. Must verify previous approval is not for both PA and QL if one is on file.
Where do you find the PDL formulary for North Carolina? If not saved to your web browser.
Launch House- Client Plans page, hyperlink at top of the note section
Can we switch a NP drug for a P drug is claim has a DAW 9?
Yes. Other substitution allowed.
What are the 3 statuses found on the formulary, list them from most preferred to least preferred.
PDL, NPD, NAP
No. Must be bioequivalent.
Which plan do we process appeals for?
Vaya Health Plan
What does AL stand for on the North Carolina Formulary?
Age Limit.
How do we know if a drug is a bioequivalent?
Drug screen in NCRx. Click the GPI button.
What is the Turn Around Time?
24 hours standard, 24 urgent
We abort as received in error for Peer to Peer Request's, what else must we do before we finalize?
⦁ Leave a timestamped note
⦁ Subject: Peer to Peer Fax Request
⦁ Note Text: Attached fax is a Peer-to-Peer request. Denied in episode XXXXXX. E-mail has been sent to Clinical Reviewer for Peer-to-Peer Request
⦁ Send an e-mail to most recent Clinical Reviewer for the denied episode. Use one of the following e-mail templates (e-mail templates attached; you may create e-mail Quicksteps if you choose to):
⦁ Medicaid LOB
⦁ To - Clinical Reviewer's e-mail
⦁ CC - DL-Medicaid Clinical Prior Auth Pharmacists
If no provider fax attached to the form we receive, what system do we use to obtain the fax number?
Is the lock in program for NC Medicaid for Antipsychotic medications?
No. Opioid and benzodiazepines.
What is a MONY Y drug?
Generic, friends with O that is brand.
Are we allowed to approve Not Covered Medications?
No. Only the MCO is allowed to approve Not Covered Medications.
What does Tier 99, Tier 97, Tier 96 mean?
Not Covered. Put on ETC document.
Can we process Not Covered Diabetic Supplies for North Carolina?
No. abort out as Received in error.
Synagis Drugs. Are those required to be on a Universal form?
Yes. ⦁ Texas Universal Form and Synagis PA Form: All initial requests received on or after 10/2/2023 will require the Tx Universal Form (new form - see attachments) AND the Synagis PA form to be accepted.
Explain what a 72 Hour Emergency Fill is in your own words.