Pharmacy Services

If you go to a drug store that is not in our network, you may not be able to fill your medications, or may have to pay out of pocket yourself. You can ask for an exception for emergency situations. To submit an exception request, click here.

• Generic substitution is when the benefit will require members to only use a generic drug. Therapeutic interchange is when the doctor prescribes a drug, but the pharmacy dispenses one that is chemically different but works the same. Any changes to your medicine should only be made with your doctor's consideration.
• Texas Children’s Health Plan will not deny any coverage of any product covered under Medicaid/CHIP benefits. This includes brand or generic drugs on the formulary. Texas Children’s Health Plan will only process claims as written by your doctor.

• Medications included in you or your child’s prescription benefit are part of the Texas Medicaid/CHIP formulary. The formulary is a list of brand and generic medicines of quality and value. You can review the full formulary by visiting our PBM’s website: https://txstarchip.navitus.com/formulary or the Texas Vendor Drug website: https://www.txvendordrug.com/formulary
• The formulary also identifies which medications require prior authorization, and which medications are on a preferred drug list (PDL). Texas Health and Human Services creates and maintains the drug formulary for Medicaid and CHIP. The PDL is updated every 6 months in January and July. You can review the latest PDL by visiting the Texas Vendor Drug Website: https://www.txvendordrug.com/formulary/preferred-drugs

• You may receive a 72-hour (3-day) emergency supply of a prescribed drug if a medication is needed without delay and prior authorization (PA) is not available. This applies to all drugs requiring a PA, either because they are non-preferred drugs on the Preferred Drug List or because they are subject to clinical edits. The pharmacist at your pharmacy will ultimately decide if they want to dispense the 3-day supply or not. The choice is up to the pharmacist.
• The 72-hour emergency supply should be dispensed any time a PA cannot be fixed within 24 hours for a medication on the Vendor Drug Program formulary that is appropriate for the member’s medical condition. If the prescribing provider cannot be reached or is unable to ask for a PA, the drug store should submit an emergency 72-hour prescription.
• A drug store can dispense a product that is packaged in a dosage form that is fixed and unbreakable, e.g., an albuterol inhaler, as a 72-hour emergency supply.
• For more information, please call Member Services toll-free at 1-866-959-6555 (CHIP) or 1-866-959-2555 (STAR), or 1-800-659-5764 (STAR Kids).

• A group of doctors and pharmacists from the Texas Drug Utilization Review board review the formulary on an ongoing basis. Only drugs that are safe, effective and affordable are included. The formulary, preferred drug list and prior authorization criteria are all decided by the Texas Vendor Drug Program at Texas Health Human and Services.
• You can review the list of medications by visiting txvendordrug.com.

• You can review the list of medications by visiting txvendordrug.com. There is a tool to search medications by brand or generic name. The tool also identifies if a medication requires prior authorization requirements.
• You can also review the list of drugs from our PBM’s website at https://txstarchip.navitus.com/formulary
• You can also contact Texas Children’s Health Plan to speak to a pharmacist if you have any questions about your medications and benefits. Contact Member Services at 1-866-959-6555 (CHIP) or 1-866-959-2555 (STAR), or 1-800-659-5764 (STAR Kids) if you need help.

• A PBM is a company that manages drug store benefits. Navitus is Texas Children's Health Plan's PBM. Navitus is responsible for:
  • Maintaining Texas Children's Health Plan's network of drug stores.
  • Helping drug store process claims.
  • Ensuring only claims covered under the Texas STAR and CHIP drug formulary are processed.
  • Reviewing prior approval requests from doctors for drugs that require pre-approval.
  • Reviewing exceptions for quantity limits or high doses.

Texas Children’s Health Plan allows up to 34-days’ supply of medicines per fill. You may request an exception for a refill by contacting Member Services at 1-866-959-6555 (CHIP) or 1-866-959-2555 (STAR), or 1-800-659-5764 (STAR Kids).

Some medicines need a pre-approval before you can fill them at a drug store. Pre-approvals make sure that the drug is safe and effective and/or drugs not on the preferred drug list. Your doctor must submit a prior authorization request. We work with Navitus Health Solutions, a pharmacy benefit manager (PBM) to review prior authorization requests. Decisions are made within 72 hours. A list of prior authorization forms may be found on your online member portal, or at txstarchip.navitus.com under “Prior Authorization Forms.”

The Texas Children’s Health Plan Medicaid Prior Authorization clinical criteria is available from the Navitus pharmacy benefit manager website under “Clinical Edits.”

You can search for the preferred drug list (PDL) by visiting the Texas Health and Human Services (HHSC) Vendor Drug website at txvendordrug.com. The PDL is controlled by HHSC. Texas Children’s Health Plan is required to follow PDL requirements. The PDL is updated every 6 months in January and July. Texas Children’s will notify you directly if there are negative changes that impact your ability to obtain your medications. We also provide information on our website before a change.

• If your pre-approval will be denied based on the criteria, your doctor may request an exception by appealing the pre-approval denial. Your doctor may also submit a separate “exception to request” prior authorization form for high dose drugs, or for requests beyond standard quantity limits. The Exception to Coverage form can be found at txstarchip.navitus.com under “Prior Authorization Forms.”
• If you are out of state, or need a drug not on the drug list, or have any other problem getting your or your child’s medications, you or your doctor may call Member Services at 1-866-959-6555 (CHIP) or 1-866-959-2555 (STAR), or 1-800-659-5764 (STAR Kids). Your provider can also appeal a pre-approval denial if you and your provider believe you need the medication.

• If you or your doctor does not agree with a pre-approval request decision, you have the right to submit an appeal. Texas Children’s Health Plan reviews all appeal requests. Instructions on how to appeal are included in the prior authorization denial letter.
• If you have a concern about a drug store benefit, claim, or other service, please call Member Services toll-free at 1-866-959-6555 (CHIP) or 1-866-959-2555 (STAR), or 1-800-659-5764 (STAR Kids).

If your or your child’s doctor cannot be reached to approve a prescription, you or your child may be able to get a three-day (72- hour) emergency supply of your or your child’s medication. Ask your drug store about providing you or your child an emergency supply. You can also call Texas Children’s Health Plan toll-free at 1-866-959-6555 (CHIP) or 1-866-959-2555 (STAR), or 1-800-659-5764 (STAR Kids) for help.

If you need your medication(s) delivered, you can use a pharmacy in our network that provides delivery services. You can search for a pharmacy that provides delivery services using our “Find a Pharmacy” online search tool, or you can call Member Services toll-free at 1-866-959-6555 (CHIP) or 1-866-959-2555 (STAR), or 1-800-659-5764 (STAR Kids).

• Your prescription medicines are a benefit through your Texas STAR/STAR Kids/CHIP coverage. You will need to obtain the medication through a drug store in Texas Children's Health Plan network. Always bring your prescription, your Texas Children’s Health Plan ID card and your Texas Medicaid ID card with you to the drug store.
• You can contact our Member Services Team if you have questions about your prescription drug benefits. You can also search our website or use our online portal to view and manage your benefits.

If you lose your medications, you should call your doctor or clinic for help. If your doctor or clinic is closed, the drug store may be able to provide an emergency 72-hour supply. Sometimes, you may need special permission from the Texas Children’s Health Plan for an early refill. You can call Member Services toll-free at 1-866-959-6555 (CHIP) or 1-866-959-2555 (STAR), or 1-800-659-5764 (STAR Kids).

• Your doctor will write a prescription so you can take it to the drug store, or may be able to send the prescription for you. You or your child’s doctor can choose from a list of medications approved by the Texas Vendor Drug Program (VDP).
• If you need help finding a drug store near you or one that can deliver medications directly to your home, call us toll-free at 1-866-959-6555 (CHIP) or 1-866-959-2555 (STAR), or 1-800-659-5764 (STAR Kids)

The pharmacy cannot give you an over-the-counter medication as part of your/your child’s Medicaid benefit. If you need/your child needs an over-the-counter medication, you will have to pay for it unless it is on the formulary and the provider writes a prescription for it.

• Use our “Find a Pharmacy” online search tool above to easily find a convenient pharmacy within our network.
• You can also call Member Services toll-free at 1-866-959-6555 (CHIP) or 1-866-959-2555 (STAR), or 1-800-659-5764 (STAR Kids) to find a drug store in our network. We can help you find pharmacies that deliver medications for free, are open 24 hours a day 7 days a week, are handicap accessible or speak different languages.

The drug store can only give you an amount of a medication that you need/your child needs for the next 34 days. For exception requests, please call Texas Children’s Health Plan Member Services toll-free at 1-866-959-6555 (CHIP) or 1-866-959-2555 (STAR), or 1-800-659-5764 (STAR Kids).

• The Lock-In Program is designed to both manage the inappropriate use of medical services and to promote safety. You may be put in the Lock-in Program if you do not follow Medicaid rules. It checks how you use Medicaid drug store services. This can include activity that can be considered dangerous, excessive, or potentially fraudulent.
• If you are selected for the lock-in program, you must get all of your medications from a single drug store. You will get a letter from the Office of Inspector General notifying you of the drug store you are locked into and the start date. Lock-ins may range from 36 to 60 months.
• Your Medicaid benefits will remain the same. Changing to a different health plan will not change the Lock-In status.
• If you are locked into a drug store but have an urgent/immediate medication need that the locked-in drug store cannot meet, please contact Member Services immediately. We will review your request on a case-by-case basis.

• Pick one drugstore at one location to use all the time.
• Be sure your main doctor, main dentist, or the specialists they refer you to are the only doctors that give you prescriptions.
• Do not get the same type of medicine from different doctors.
• To learn more, call Member Services toll-free at 1-866-959-6555 (CHIP) or 1-866-959-2555 (STAR), or 1-800-659-5764 (STAR Kids) and ask to speak to a pharmacist about the Medicaid Lock-In Program.

You do not have a copayment for prescription medications covered under the Medicaid benefit.

Some Medicare plans may not have pharmacy benefit coverage. If you or your child have Medicare and Medicaid pharmacy benefit coverage, please bring both insurance cards to the Pharmacy. Medicare will pay first up to the limits of its coverage. Medicaid will cover the remaining costs if within the limits of its coverage. Medicines covered under Medicare-Medicaid dual coverage may not be the same as typical Medicaid only benefits.

If you are in a Nursing facility, they will provide you with medications.

Coverage does not include contraceptive medications prescribed only for the purpose of preventing a pregnancy and medications for weight loss or gain. You may have to pay a copayment for each prescription filled depending on your income. There are no copayments for CHIP Perinate Members.

The pharmacy cannot give you or your child birth control pills to prevent pregnancy. You or your child can only get birth control pills if they are needed to treat a medical condition.