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Pharmacy Information

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Pharmacy Provider Training

Our mission is to provide the most personalized, comprehensive and highest quality healthcare, enhanced by medical education and research. Training documents, additional information, payer sheets and an updated handbook that contains Texas Managed Medicaid procedures and policies are also available on the Navitus Health Solutions website.

Pharmacy Information

Formulary

Pharmacy Benefit Drugs
  • RightCare is state mandated to adhere to the Texas Medicaid Formulary, Preferred Drug List, Provisional Formulary and Preferred Drug List Criteria Guide are developed and maintained by the Texas Drug Utilization Review (DUR) Board and Texas HHSC Vendor Drug Program (VDP). Additional information regarding VDP including formularies, preferred drug list and Texas DUR Board meeting minutes and updates can be found on theTexas Vendor Drug Program webpage.
  • The Texas Medicaid formulary and Preferred Drug List are available on the Epocrates drug information system. The service is free and provides instant access to information about the Texas Medicaid formulary through the internet or a handheld device.
  • The Texas STAR Formulary is available in paper form without charge. To request a copy, call RightCare Customer Service at 855-897-4448.
Medical Benefit Drugs

Prior Authorizations

Pharmacy Benefit Drugs
  • RightCare administers the prior authorization criteria approved by the Texas DUR Board.
  • To obtain pharmacy prior authorization assistance for Medicaid, call RightCare Medicaid PBM, Navitus, toll free at 877-908-6023 and select the prescriber option to speak with the Prior Authorization department from 6 a.m. to 6 p.m. weekdays and 8 a.m. to noon weekends CT, excluding state approved holidays.
  • Download the State of Texas Standard Prior Authorization Form for prescription benefit drugs.
  • STAR Pharmacy Prior Authorization Timelines
    • If the prescriber's office calls the MCO's PA call center, the MCO must provide prior authorization approval or denial immediately.
    • For all other PA requests, the MCO must notify the prescriber's office of a PA denial or approval no later than 24 hours after receipt.
    • If the MCO cannot provide a response to the PA request within 24 hours after receipt or the prescriber is not available to make a PA request because it is after the prescriber's office hours and the dispensing pharmacist determines it is an emergency situation, the MCO must allow the pharmacy to dispense a 72-hour supply of the drug.

A 72-hour emergency supply of a prescribed drug may be provided when a medication is needed without delay and prior authorization (PA) is not available. This applies to all drugs requiring a prior authorization (PA), either because they are non-preferred drugs on the Preferred Drug List or because they are subject to clinical edits.

The 72-hour emergency supply may be dispensed when a PA cannot be resolved 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 request a PA, the pharmacy should submit an emergency 72-hour prescription. The emergency supply is subject to pharmacist clinical judgement. Some non-urgent medications are exempt from this emergency supply.

A pharmacy 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.

To be reimbursed for a 72-hour emergency prescription supply, pharmacies should submit the following information:

Claim Submission Process:

Place '8' in "Prior Authorization Type Code" (Field 461-EU), '801' in "Prior Authorization Number Submitted" (Field 462-EV) and '3' in "Days' Supply" in the claim segment of the billing transaction (Field 405-D5). The quantity submitted in "Quantity Dispensed" (Field 442-E7) should not exceed the quantity necessary for a three-day supply. It is permissible that a pharmacy dispense product packages in fixed dosage forms (e.g., inhalers, nebulized medications) that are unbreakable as a 72-hour supply. Place '3' in "Days' Supply" but enter the full quantity dispensed.

Medical Benefit Drugs

For information regarding prior authorization submission for drugs obtained under the medical benefit, please refer to Authorizations

Pharmacy Provider Manual

  • To obtain a copy of the Pharmacy Provider Manual, please visit navitus.com.
  • For Pharmacy questions contact RightCare Customer Service at 855-897-4448.

Pharmacy Maximum Allowable Cost (MAC) List