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Pharmacy Program

 

Pharmacy Manuals and Training 

View Pharmacy Provider Manual (PDF 442.69 KB)

OptumRx Pharmacy Manual is available at http://learn.optumrx.com/pharmacymanual and should be reviewed in conjunction with UHC TX Pharmacy Provider Manual. 

View additional Provider Training

 


Children's Health Insurance Program (CHIP)

Pharmacy Program 

 

Formulary Information

Formulary Look Up Tool

Pharmacy Bulletins 

For important announcements from the Texas Health and Human Services Commission, please go to the Provider Information tab.

New Prescription OptumRx Mail In Order Form

 

Pharmacy Prior Authorization Forms

Prior authorization is required for some services and medications. A current list of prior authorization services, medications and forms can be found below.

General Pharmacy Prior Authorization Form (PDF 52.3 KB)
Opioid Medications Prior Authorization Form
(PDF 93.5 KB)
Standard Prior Authorization Form
(PDF 1.04 MB)
 

 

UnitedHealthcare Community Plan works with OptumRx to manage the Pharmacy network. Multiple sources are used by OptumRx in order to assure the Maximum Allowable Cost (MAC) list accurately reflects market pricing and availability of generic drugs.

Texas MAC Price Lookup

MAC Appeal Submission Guide

For general contract information, please contact OptumRx at 1-800-797-9798.

Pharmacies with specific claim related questions should contact OptumRx at 1-866-328-3108


STAR

Pharmacy Program 

 

Formulary Information

Formulary Look Up Tool

 

Preferred Drug List

The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by STAR. Click on the link below to view the Preferred Drug List.

Preferred Drug List (PDL) Search


Pharmacy Bulletins 

For important announcements from the Texas Health and Human Services Commission, please go to the Provider Information tab.

New Prescription OptumRx Mail In Order Form
Pharmacy Flu Vaccine and Immunization / Injection Billing Guidelines

Texas Health Steps

Texas Vitamins and Minerals

Synagis Program

 

Pharmacy Prior Authorization Forms

Prior authorization is required for some services and medications. A current list of prior authorization services, medications and forms can be found below.

Standard Prior Authorization Form (PDF 1.04 MB) - posted 5.19.2016

 

UnitedHealthcare Community Plan works with OptumRx to manage the Pharmacy network. Multiple sources are used by OptumRx in order to assure the Maximum Allowable Cost (MAC) list accurately reflects market pricing and availability of generic drugs.

Texas MAC Price Lookup

MAC Appeal Submission Guide

For general contract information, please contact OptumRx at 1-800-797-9798.

Pharmacies with specific claim related questions should contact OptumRx at 1-866-328-3108

 

Clinical Pharmacy Program Guidelines 

UnitedHealthcare Community Plan’s Clinical Pharmacy Program Guidelines are updated on an ongoing basis by our Pharmacy and Therapeutics Committee. Our changes reflect recent developments in pharmaceutical health care so we’re aligned with national treatment standards.

 

Limited Home Health Supplies (LHHS) 

Texas allows certain supplies (Limited Home Health Supplies or LHHS) that are covered benefits of Texas Medicaid to be provided by a pharmacy benefit.

Our network of pharmacies will be allowed to provide a limited set of basic home health supplies to clients enrolled in Medicaid (STAR and STAR+PLUS members).

More information regarding this program, including a list of supplies available through the Texas Medicaid Preferred Drug List (PDL) can be found at https://www.txvendordrug.com/formulary/home-health-supplies and TX Pharmacies May Dispense Limited Home Health Supplies (PDF 35.49 KB).

 

2016 Changes for Preferred Diabetic Test Strip 

Effective Jan. 1, 2016, only LifeScan (OneTouch®) test strips will be the only preferred test strips on the Preferred Drug List.

Effective Jan. 1, 2016, only LifeScan (OneTouch®) test strips will be the only preferred test strips on the Preferred Drug List. The other manufacturers of tests strips, including Roche (Accu-Chek®), will be removed from the Preferred Drug List and become non-preferred.

Preferred Diabetic Test Strips

OneTouch Ultra Test Strips

OneTouch Verio Test Strips 

* OneTouch Ultra or OneTouch Verio meters are available to your patients at no cost with a prescription. Please write a prescription for a One Touch meter and test strips and the Pharmacy will dispense it. 

Encourage your patients to use the preferred products and provide them with a new prescription for these products.

If the preferred alternative testing supplies are not appropriate for your patients, they may still obtain the non-preferred brand through a DME provider and you will not need to do anything different to keep your patient on the non-preferred product.

If you have questions, call Provider Services at 888-887-9003 Monday-Friday, 8 a.m. – 6 p.m. CST.


STAR Kids

Pharmacy Program 


Formulary Information 

Formulary Look Up Tool

 

Preferred Drug List

The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by STAR Kids.

Click on the link below to view the Preferred Drug List.

Preferred Drug List (PDL) Search


Pharmacy Bulletins

For important announcements from the Texas Health and Human Services Commission, please go to the Provider Information tab.

New Prescription OptumRx Mail In Order Form (PDF 86.06 KB)
Important Information for Participating Pharmacies
(PDF 744.07 KB)
Synagis Program (PDF 59.32 KB)
Texas Health Steps
(PDF 521.41 KB)
Texas Vitamins and Minerals
(PDF 67.06 KB)

 

Pharmacy Prior Authorization Forms

Prior authorization is required for some services and medications. A current list of prior authorization services, medications and forms can be found below.

Standard Prior Authorization Form (PDF 1.04 MB) - posted 5.19.2016 

 

Clinical Pharmacy Program Guidelines 

UnitedHealthcare Community Plan’s Clinical Pharmacy Program Guidelines are updated on an ongoing basis by our Pharmacy and Therapeutics Committee. Our changes reflect recent developments in pharmaceutical health care so we’re aligned with national treatment standards.

 

Limited Home Health Supplies (LHHS) 

Texas allows certain supplies (Limited Home Health Supplies or LHHS) that are covered benefits of Texas Medicaid to be provided by a pharmacy benefit.

Our network of pharmacies will be allowed to provide a limited set of basic home health supplies to clients enrolled in Medicaid (STAR and STAR+PLUS members).

More information regarding this program, including a list of supplies available through the Texas Medicaid Preferred Drug List (PDL) can be found at https://www.txvendordrug.com/formulary/home-health-supplies and TX Pharmacies May Dispense Limited Home Health Supplies (PDF 35.49 KB).

 

2016 Changes for Preferred Diabetic Test Strip 

Effective Jan. 1, 2016, only LifeScan (OneTouch®) test strips will be the only preferred test strips on the Preferred Drug List.

Effective Jan. 1, 2016, only LifeScan (OneTouch®) test strips will be the only preferred test strips on the Preferred Drug List. The other manufacturers of tests strips, including Roche (Accu-Chek®), will be removed from the Preferred Drug List and become non-preferred.

Preferred Diabetic Test Strips

OneTouch Ultra Test Strips

OneTouch Verio Test Strips 

* OneTouch Ultra or OneTouch Verio meters are available to your patients at no cost with a prescription. Please write a prescription for a One Touch meter and test strips and the Pharmacy will dispense it. 

Encourage your patients to use the preferred products and provide them with a new prescription for these products.

If the preferred alternative testing supplies are not appropriate for your patients, they may still obtain the non-preferred brand through a DME provider and you will not need to do anything different to keep your patient on the non-preferred product.

If you have questions, call Provider Services at 888-887-9003 Monday-Friday, 8 a.m. – 6 p.m. CST.

UnitedHealthcare Community Plan works with OptumRx to manage the Pharmacy network. Multiple sources are used by OptumRx in order to assure the Maximum Allowable Cost (MAC) list accurately reflects market pricing and availability of generic drugs.

Texas MAC Price Lookup

MAC Appeal Submission Guide

For general contract information, please contact OptumRx at 1-800-797-9798.

Pharmacies with specific claim related questions should contact OptumRx at 1-866-328-3108


STAR+PLUS

Pharmacy Program 


Formulary Information 

Formulary Look Up Tool

 

Preferred Drug List 

The Preferred Drug List (PDL) is a list of prescription drugs considered coverable by STAR+Plus.

Click on the link below to view the Preferred Drug List.

Preferred Drug List (PDL) Search


Pharmacy Bulletins

For important announcements from the Texas Health and Human Services Commission, please go to the Provider Information tab.

New Prescription OptumRx Mail In Order Form (PDF 86.06 KB)
Pharmacy Flu Vaccine and Immunization / Injection Billing Guidelines
(PDF 50.17 KB)
Synagis Program
(PDF 59.32 KB)
Texas Health Steps
(PDF 521.41 KB)
Texas Vitamins and Minerals
(PDF 67.06 KB)

 

Pharmacy Prior Authorization Forms

Prior authorization is required for some services and medications. A current list of prior authorization services, medications and forms can be found below.

Standard Prior Authorization Form (PDF 1.04 MB) - posted 5.19.2016

Texas Vendor Drug Program Clinical Edit Criteria

Implemented Clinical Prior Authorization Criteria/Logic (PDF 47.28 KB)

Texas now allows certain supplies (Limited Home Health Supplies or LHHS) that are covered benefits of Texas Medicaid to be provided by a pharmacy benefit. As of November 12, 2012, our network of pharmacies will be allowed to provide a limited set of basic home health supplies to clients enrolled in Medicaid (STAR and STAR+PLUS members). More
information regarding this program, including a list of supplies available through the Texas Medicaid PDL can be found here: http://www.txvendordrug.com/formulary/limited-hhs.shtml and here: TX Pharmacies May Dispense Limited Home Health Supplies (PDF 35.49 KB)

 

Clinical Pharmacy Program Guidelines 

UnitedHealthcare Community Plan’s Clinical Pharmacy Program Guidelines are updated on an ongoing basis by our Pharmacy and Therapeutics Committee. Our changes reflect recent developments in pharmaceutical health care so we’re aligned with national treatment standards.

 

Limited Home Health Supplies (LHHS) 

Texas allows certain supplies (Limited Home Health Supplies or LHHS) that are covered benefits of Texas Medicaid to be provided by a pharmacy benefit.

Our network of pharmacies will be allowed to provide a limited set of basic home health supplies to clients enrolled in Medicaid (STAR and STAR+PLUS members).

More information regarding this program, including a list of supplies available through the Texas Medicaid Preferred Drug List (PDL) can be found at https://www.txvendordrug.com/formulary/home-health-supplies and TX Pharmacies May Dispense Limited Home Health Supplies (PDF 35.49 KB).

 

2016 Changes for Preferred Diabetic Test Strip 

Effective Jan. 1, 2016, only LifeScan (OneTouch®) test strips will be the only preferred test strips on the Preferred Drug List.

Effective Jan. 1, 2016, only LifeScan (OneTouch®) test strips will be the only preferred test strips on the Preferred Drug List. The other manufacturers of tests strips, including Roche (Accu-Chek®), will be removed from the Preferred Drug List and become non-preferred.

Preferred Diabetic Test Strips

OneTouch Ultra Test Strips

OneTouch Verio Test Strips 

* OneTouch Ultra or OneTouch Verio meters are available to your patients at no cost with a prescription. Please write a prescription for a One Touch meter and test strips and the Pharmacy will dispense it. 

Encourage your patients to use the preferred products and provide them with a new prescription for these products.

If the preferred alternative testing supplies are not appropriate for your patients, they may still obtain the non-preferred brand through a DME provider and you will not need to do anything different to keep your patient on the non-preferred product.

If you have questions, call Provider Services at 888-887-9003 Monday-Friday, 8 a.m. – 6 p.m. CST.

 

UnitedHealthcare Community Plan works with OptumRx to manage the Pharmacy network. Multiple sources are used by OptumRx in order to assure the Maximum Allowable Cost (MAC) list accurately reflects market pricing and availability of generic drugs.

Texas MAC Price Lookup

MAC Appeal Submission Guide

For general contract information, please contact OptumRx at 1-800-797-9798.

Pharmacies with specific claim related questions should contact OptumRx at 1-866-328-3108


UnitedHealthcare Connected® (Medicare-Medicaid Plan)


UnitedHealthcare Dual Complete® (HMO SNP)
H4514-001


UnitedHealthcare Dual Complete® (HMO SNP)
H4590-020


UnitedHealthcare Dual Complete® (HMO SNP)
H4590-022


UnitedHealthcare Dual Complete® (HMO SNP)
H5322-025


UnitedHealthcare Dual Complete® (HMO SNP)
H5322-026


UnitedHealthcare Dual Complete® (HMO SNP)
H4590-033


UnitedHealthcare Dual Complete® (PPO SNP)
H2228-041


UnitedHealthcare Dual Complete® Focus (HMO SNP)
H4527-003


UnitedHealthcare Dual Complete® Focus (HMO SNP)
H4527-004


UnitedHealthcare Dual Complete® Focus (HMO SNP)
H4527-006


UnitedHealthcare Dual Complete® Focus (HMO SNP)
H4527-015