Pharmacy information and tools
Pharmacy information for providers, including contact information and formulary details, can be found on this page. CarelonRx* is the pharmacy benefits manager.
Medicaid and CHIP Formulary and Medicaid Preferred Drug List (PDL)
Please refer to the Texas Medicaid formulary and PDL , available on the Vendor Drug Program (VDP) website at www.txvendordrug.com .
Texas Vendor Drug Program Clinical Edits
These clinical prior authorizations apply to patients enrolled in traditional Medicaid. Texas Vendor Drug Program Clinical Edits can be viewed on the Vendor Drug Program website .
Prior Authorizations
Providers are encouraged to write prescriptions for preferred products as listed on the Texas Medicaid formulary and Preferred Drug List (PDL), available on the Vendor Drug Program (VDP) website at https://www.txvendordrug.com/formulary/prior-authorization .
If, for medical reasons, a member cannot use a preferred product, providers are required to contact the Pharmacy department at Amerigroup at 1-800-454-3730 to obtain prior authorization. CHIP members’ claims will not require PDL prior authorization.
Pharmacy department:
1-800-454-3730
Medications that require prior authorization may include:
- Drugs listed as nonpreferred on the PDL or drugs that require clinical prior authorization.
- Select self-administered injectable products.
- Drugs that exceed certain cost and/or dosing limits. (For information on these limits, call Amerigroup Pharmacy at 1-800-454-3730.)
Note: This list is not all-inclusive and is subject to change.
Pharmacy Prior Authorization Submissions
Online pharmacy prior authorization: https://www.covermymeds.com
Pharmacy prior authorization fax:
1-844-474-3341, available 24/7
Pharmacy phone (at Amerigroup):
1-800-454-3730, available 7 a.m. to 10 p.m. Central time
Medical injectable/infusible drugs prior authorization fax:
Prior authorization fax:
1-844-512-8995, available 24/7
Medicare
All Amerigroup Amerivantage (Medicare Advantage) plans include coverage of Medicare Part D prescription drugs, as well as those covered under Medicare Part B.
View the formulary for individual Medicare Advantage products:
Medicare Part D Rx coverage determinations
Providers can send a request for a prescription coverage determination for a Medicare plan via electronic prior authorization (ePA) rather than fax or phone by submitting the request from one of the following ePA websites:
Amerigroup STAR+PLUS MMP (Medicare-Medicaid Plan)
Members have access to most national pharmacy chains and many independent retail pharmacies that are contracted with us. Members may obtain their medications at any network pharmacy.
Clinical Pharmacy Policies
Drug coverage policies are based on medical necessity considerations subject to applicable benefits. These policies assist with medical necessity coverage decisions, may include state-specific guidance regarding coverage and do not constitute medical advice. Benefit determination is based on the applicable contract language and/or state requirements.
These policies are not a guarantee of coverage. Contract language or state requirements will prevail when there are conflicts with any medication coverage policy. In all cases, Medicaid contracts or CMS requirements supersede policy criteria.
Related information
Provider tools & resources
- Log in to Availity
- Launch Provider Learning Hub Now
- Learn about Availity
- Precertification Lookup Tool
- Prior Authorization Requirements
- Claims Overview
- Member Eligibility & Pharmacy Overview
- Provider Manuals and Guides
- Referrals
- Forms
- Training Academy
- Pharmacy Information
- Electronic Data Interchange (EDI)