Texas Medicaid: Help avoid pharmacy prior authorization delays

Submit required clinical documentation to support pharmacy prior authorization requests

Some pharmacy prior authorization requests require clinical documentation to support a medical necessity determination. Any clinical document that supports medical necessity for the medication must be submitted along with the prior authorization request form.

If supporting documentation isn’t included with a pharmacy prior authorization request, it may not be approved. Turnaround time for standard and urgent pharmacy prior authorization review is 24 hours.

Additional information on which documentation is required for a pharmacy prior authorization request can be found in the Clinical Prior Authorization Guidelines. 

More details

Supporting documentation requirements are based on clinical criteria in UnitedHealthcare pharmacy policies and guidance from UnitedHealthcare physicians and pharmacists with experience in reviewing service requests for pharmacy coverage. Additionally, some requirements for supporting documentation are determined by the Texas Health and Human Services Commission (HHSC).

For example, supporting documentation is needed if a provider requests drugs like Humira. In those cases, a provider is required to submit medical notes documenting:

• The patient’s recent medical and medication history
• The patient’s diagnosis history
• The patient’s condition, allergies and chronic diseases 
• Other specific criteria (see coverage rationale) that qualify the individual for the drug

How to submit a request

You can submit a prior authorization request through the UnitedHealthcare Provider Portal:

• Go to UHCprovider.com and click Sign In at the top-right corner
• Enter your One Healthcare ID and password
  • New users who don’t have a One Healthcare ID: Visit UHCprovider.com/access to get started
• In the menu, select Prior Authorizations 
• Scroll down to “Create a new notification or prior authorization request” and select Create New Submissions
• In the drop-down “Select prior authorization type for submission,” select “Specialty Pharmacy” from the drop-down list and the Plan Type.
• Enter the required information and submit

Other ways to submit a pharmacy prior authorization request include:

• Telephone: 1-800-310-6826
• Fax: 1-866-940-7328
• Electronically by CoverMyMeds or PreCheck My Script