- For routine and urgent approvals, written/letter notification is required no later than the second business day after the date of the request
- For a member that is not hospitalized at the time of an adverse determination, notification will be provided within three business days in writing to the requesting provider and the member
Medicaid/CHIP pharmacy prior authorization submissions
Online pharmacy prior authorization: CoverMyMeds
Pharmacy prior authorization fax:
Pharmacy phone (at Wellpoint):
Available 7 a.m. to 10 p.m. CT
Medical injectable/infusible drugs prior authorization fax:
Prescriber offices calling our pharmacy prior authorization call center will receive an authorization approval or denial immediately. For all other prior authorization requests, Wellpoint will notify the prescriber’s office of an approval or denial no later than 24 hours after receipt.
If Wellpoint cannot provide a response to the prior authorization request within 24 hours after receipt or the prescriber is not available to make a prior authorization request because it is after the prescriber’s office hours and the dispensing pharmacist determines it is an emergency, the pharmacy has the ability to dispense a 72-hour supply of the drug. Directions for submitting a 72-hour supply are included in messaging sent to the pharmacy. If additional assistance is needed, pharmacies may contact the CarelonRx* Help Desk at 833-252-0329.
Providers must be prepared to supply relevant clinical information regarding the member’s need for a nonpreferred product or a medication requiring prior authorization. Only the prescribing physician or one of their staff representatives can request prior authorization. Decisions are based on medical necessity and are determined according to the Texas Vendor Drug Program (VDP)-established medical criteria. Most approved requests for prior authorization will be valid for one year, although some medications may require review more often.
* CarelonRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Wellpoint.
Member assistance with prior authorizations
Members who have questions regarding prior authorizations may contact Member Services. Members can also live chat with a representative or send a secure message once a member logs into their account.
CHIP, STAR, STAR+PLUS:
Available Monday through Friday from 7 a.m. to 6 p.m. Central time
