Know Your Rights and Responsibilities
What is the Medicaid preferred drug list?
The preferred drug list (PDL) is a list of drugs that Medicaid will automatically pay for when your doctor prescribes it. If the drug your doctor prescribes is not on the list, the doctor will either have to prescribe a different drug or ask Medicaid to pay for the drug, even though it is not on the PDL. Your doctor will have to provide certain information in order to convince Medicaid to pay for a drug that is not on the list.
When will the new preferred drug list take effect?
The Medicaid PDL will be fully in effect on February 23,2004. Beginning that day, the pharmacist cannot fill a prescription that is not on the PDL unless your doctor has gotten Prior Authorization (see explanation fo Prior Authorization process below.)
How can I find out which medicines are on the list?
If you have access to the internet, you can find a list of the preferred drugs at: www.hhsc.state.tx.us/HCF/vdp/pt/PDL/program.html. If you do not have access to the internet you can request a list by mailing a written request to:
HHSC, Vendor Drug Program/Drug Use Review
MCH6301100 West 49th Street
Austin, Tx 78756
What if the medicine I take is not on the list?
If the drug your doctor prescribes (even if you are already taken the drug) is not on the preferred drug list, your doctor, or someone on the doctor's staff, will have to contact the call center to get prior authorization. Note that only your doctor or one of her staff can call for prior authorization.
What is Prior Authorization and how do I get it?
Prior Authorization is a commitment from Medicaid to pay the pharmacist for your prescription. If your medicine is not on the preferred drug list, and your doctor cannot get Prior Authorization, the pharmacist cannot dispense your medicine (unless you pay full price). As noted above, only your doctor or one of the staff can call for Prior Authorization.
What if my doctor cannot get an answer right away?
Under federal law, you are entitled to a 72 hour emergency supply of the medicine your doctor has prescribed if your doctor cannot get an immediate response to the request for Prior Authorization.
Who will decide if I can get a 72 hour emergency supply of my medicine?
As of now, the pharmacist will make this determination.
What should my doctor do if the request for "Prior Authorization" is denied?
If Prior Authorization is denied, your doctor may submit a "request for reconsideration" via mail. If the "request for reconsideration" is denied, you may appeal the decision through the Medical Fair Hearing Process.
Do I need Prior Authorization each time I fill my prescription?
No. You will only need prior authorization once per year for each drug not included on the PDL.
How to File an Appeal with the State
Asking for a State Medicaid Fair Hearing
When you file an appeal with the State you are asking for a Medicaid Fair Hearing. You have the right to ask for a Medicaid fair hearing when:
- You are told you don't qualify for Medicaid services.
- You apply for services and your request is not acted upon promptly
- You are told that your services have been reduced.
- You are told that your services have been suspended or stopped
Here are some examples of when you might request a fair hearing:
- You get a letter that says you are eligible for Medicaid.
- You or your doctor gets a letter denying a prior authorized service such as a prescription drug.
- You get a letter that says a service was denied because it is not "medically necessary" but you or your doctor thinks you need the service.
You should always receive a letter, which explains why your services were denied, reduced or suspended. The letter must have information about how to request a Medicaid fair hearing.
A fair hearing is a review and discussion of your case. It is not a court of law. A hearing officer (someone not involved in your case) will listen to your complaint, explain the rules to you and answer your questions. The hearing officer will make a final decision in writing.
You, or someone you ask to help you, can ask for an appeal by calling the Medicaid Hotline at 1-800-252-8263.
- You have 90 days from the date on the notification letter form your health plan to request a fair hearing. If you do not request a hearing within 90 days, you will lose your right to a hearing.
- You can file a request for a Medicaid fair hearing process at any time. You can file an appeal with your health plan and the state at the same time. You do not have to wait until your health plan makes a final decision before you file an appeal with the state. The state has 90 days from the date of your request to conduct the hearing and send you written notification of the decision.
- The decision of the hearing will be final. The hearing officer will send you the decision in writing. The hearing officer may agree with the original decision or he/she may overturn the decision. You do not have to a right to a Fair Hearing if the services you requested are not a cover Medicaid service.
The notice is provided as a public service by the Disability Policy Consortium.