Texas pharmacy and prescription drug benefits

Some medicines need preapproval, or an okay from us, before they can be filled. Your doctor can call Provider Services at 833-731-2162 or fax the request to 844-512-8995.

Preapprovals are necessary for drugs that:

• Have the potential for serious side effects.
• Should be prescribed only for specific usage.
• Have a high misuse or abuse potential.

The preapproval process helps us make sure you’re taking medicines safely and correctly.

You may also need preapproval when:

• Requesting a higher dosage than recommended.
• Requesting a brand-name drug that already has an FDA-approved generic version.

You can learn more about the prior authorizations (preapprovals) process on the Prior authorization requirements.

We partner with CarelonRx Specialty Pharmacy and other pharmacies to meet all your specialty medication needs.

Learn more about specialty pharmacy 

Your or your child’s doctor chooses drugs from the Texas Vendor Drug Program (VDP) formulary. The formulary is a list of all brand-name and generic drugs available in your plan. Use the formulary to search for drugs by name or type (class).

Search the formulary 

When there is a generic drug available on the VDP list, it will usually be covered in place of the brand-name drug. Generic drugs are equal to brand-name drugs as approved by the Food and Drug Administration (FDA). If your prescription says you need the brand-name drug, we will cover the brand-name drug instead of giving you a generic.

If you need a drug that isn’t listed on our formulary, you or your representative can request a formulary exception at submitmyexceptionreq@Wellpoint.com.

You can call Member Services to have a printed copy of the formulary mailed to you at no cost. It will be sent within five business days of your request.

Wellpoint uses Texas Vendor Drug Program (VDP) Prior Authorization criteria.

VDP publishes a Clinical Prior Authorization Assistance Chart that shows which policies each Managed Care Organization has opted into.

For Medicaid members, the Preferred Drug List (PDL) shows which drugs the VDP recommends your doctor try first. Preferred products are available without prior authorization, although they may be subject to clinical prior authorization. Drugs identified as non-preferred on the PDL require a prior authorization.

Preferred Drug List 

This list does not apply to CHIP members.

Copays are a set dollar amount you pay for covered services, like doctor visits or prescriptions.

STAR, STAR Kids, and STAR+PLUS members

You don’t have pharmacy copays. If you have both Medicare and Medicaid, contact your Medicare Part D plan to learn more about your pharmacy benefits.

CHIP members

There may be copays for your child’s prescriptions. Review your child’s member handbook or member ID card for copay amounts.

CHIP Perinate members

You don’t have pharmacy copays.