Benefits and Claims

  • Pharmacy Benefit Manager (Prime Therapeutics) Information for Claims Processing 

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    Prime Therapeutics offers e-prescribing administered through SureScripts® , which allows providers to:

    • Submit prescriptions electronically
    • Verify Member eligibility
    • Review medical history
    • Review formulary information
  • Member Eligibility 

    Providers should confirm eligibility prior to providing services. Medicaid ID numbers should not change with this transition. If pharmacies have filled other prescriptions for these members, they can get information regarding client eligibility via an interactive voice response (IVR) system using the client's Medicaid ID number. This IVR system is provided by the Medicaid Eligibility and Health Information Services (MEHIS) project, in support of the "Your Texas Benefits Card."

    Members may call BCBSTX customer service with eligibility-related questions.

    • STAR and CHIP at 1-888-657-6061
    • STAR Kids at 1-877-688-1811

    If a member is unaware of which program he/she is enrolled in, the member may contact the Medicaid Managed Care enrollment broker. Members may also continue to call '211' and the Medicaid Client Line at 1-800-335-8957 for assistance with eligibility-related issues.

  • Cost to Member 
    Member Type Copay for up to 34 day supply
    STAR No Copay
    STAR Kids No Copay
    CHIP < 100% FPL $0 for generic; $3 for brand name
    CHIP 101-150% FPL $0 for generic; $5 for brand name
    CHIP 151-185% FPL $10 for generic; $35 for brand name
    CHIP 186-200% FPL $10 for generic; $35 for brand name
    CHIP Perinate No copay
    CHIP AIAN No copay
    CHIP No Cost Share No copay
  • Prescription Drug Benefits 

    Pharmacy benefits are determined by Medicaid/CHIP Vendor Drug Program (VDP) and are administered by BCBSTX. This plan goes by a list of preferred drugs. The Drug List (also called a formulary) is a list showing the drugs that can be covered by the plan.

    Certain drugs on the list need prior authorization before these drugs can be prescribed. Without approval, the drugs are not covered. For some drugs, there may be limits to the amount that will be covered. More information can be found about any added conditions or limits by looking at the Drug List or by searching the Drug List.

    There are many ways a doctor may submit a prior authorization request.

    STAR Kids Dual Members

    STAR Kids Dual members are individuals who are both Medicare eligible and also eligible for some level of Medicaid prescription coverage.

    Most drugs are covered by another primary Medicare Part D insurance plan and follow Medicare rules. Pharmacies should bill these drugs directly to the other primary Medicare Part D plan. Medicaid is the payor of last resort and provide wraparound benefit.

    BCBSTX will continue to pay for some drugs not covered by Medicare (wraparound benefit), including:

    • Over-the-counter drugs
    • cough and colds products
    • vitamins and mineral products
    • limited home health supplies

    If a member has not enrolled in a Part D prescription drug plan or have issues obtaining your Medicare drugs, contact the Limited Income Newly Eligible Transition (LI-NET) program at 1-800-783-1307 for help. Find more information at by searching for the LI-NET program.

  • Quantity Supply Limits 

    Our pharmacy benefits allow up to a 34-day supply of medication. This program defines a standard 34-day supply of medication for a select list of medications. If a medical condition warrants a greater quantity supply than the defined 34-day supply of medication, Prior Authorization will ensure access to the prescribed quantity. Prior to dispensing, a written prior authorization needs to be submitted to BCBSTX to determine medical necessity.

  • Dose Optimization

    The Dose Optimization Program, or dose consolidation, is an extension to the Quantity Supply Program, which helps increase patient adherence with drug therapies. This program works with the member, the member's physician or health care provider, and the pharmacist to replace multiple doses of lower strength medications where clinically appropriate with a single dose of a higher-strength medication (only with the prescribing physician's approval). Prior to dispensing of multiple doses of the lower strength medications, a written prior authorization needs to be submitted for an internal review by BCBSTX to determine medical necessity.

  • Benefit Exclusions

    Benefit exclusions are those services that are not covered under the pharmacy benefit which include the following medications:

    • Infertility Medications
    • Erectile Dysfunction Medications
    • Cosmetic and Hair Growth Medications
    • Dietary Supplements
    • Drugs not approved by the FDA
    • Over the counter drugs for CHIP/CHIP Perinate Members
    • Contraceptive agents used for family planning for CHIP/CHIP Perinate

    Pharmacies can override claims submitted for these drugs for a non-contraceptive diagnosis and do not require a call to our Help Desk. When transmitting these claims, pharmacies should submit the following values:

    • Prior Authorization Type Code (Field 461-EU)
      • “2” = Medical Certification
    • Prior Authorization Number Submitted (Field 462-EV)
      • “31” = Dysmenorrhea
      • “32” = Acne Treatment
      • “33” = Miscellaneous, other than contraception