Cook Children's Health Plan uses Navitus Health Solutions as their Pharmacy Benefit Manager (PBM).
Please visit the Navitus website for the following pharmacy information:
Visit the Texas Medicaid/CHIP Vendor Drug Program (VDP) to view the:
Healthy members are very important to us. Use the Navitus web portal for members to find information about:
- General Pharmacy Benefit Information
- Search for generic substitues
- Pharmacy Search
- Drug Search
- Drug recall notifications
- Easy access to direct member reimbursement (paper) claim forms
Toll Free: 1-800-964-2247
Local TTY/TDD: 682-885-2138
Toll Free TTY/TDD: 1-844-644-4137
For Pharmacies and Prescribers Only:
Toll Free: 1-877-908-6023
Hours of Operation: 8 a.m. to 5 p.m. Monday through Friday, except for State Holidays. If you call after 5pm or the weekend or holiday, leave a message and your call will be returned the next business day. All of our Member Services Representatives are bilingual in English and Spanish.
Member/Provider Website: Navitus (https://www.navitus.com/members)
What are my prescription drug benefits?
Your prescription drugs are a benefit through your Medicaid (STAR) and CHIP coverages. Your doctor will write a prescription so you can take it to the drugstore or may be able to send the prescription for you. Adults as well as children can get as many prescriptions as are medically necessary.
What do I bring with me to the drug store?
You must take your Cook Children's Health Plan ID card with you when you go to the drug store to get a prescription.
What if I need my medications delivered to me?
Call Member Services for assistance with finding a pharmacy that delivers.
- CHIP/STAR Members can call 1-800-964-2247
- STAR Kids Members can call 1-800-844-0004
How do I find a network drug store?
You may have your prescription filled at any drug store that accepts Cook Children's Health Plan. You can use the online pharmacy directory listed above or Call Member Services:
- CHIP/STAR Members can call 1-800-964-2247
STAR Kids Members can call 1-800-844-0004
What if I go to a drug store not in the network?
If you go to a pharmacy that is not in our network, that pharmacy can call the pharmacist help line number on your/your child's Cook Children's Health Plan ID card. They can help you get your prescription. Call us if you are out of state and need emergency prescriptions. If we cannot find a pharmacy that is in the Cook Children's Health Plan network, we will tell you what you need to do.
Why does my prescription require a prior authorization?
Some medicines may require a prior authorization, or a preapproval, before your provider can prescribe them and the pharmacy can fill them. The preapproval process helps us make sure that you are taking medications safely and correctly.
Here are some reasons that preapproval may be required:
- There is a generic or pharmacy alternative drug available.
- There are other drugs that should be tried first.
- The drug has a high side effect potential.
- The drug is prescribed at a higher dosage than recommended.
- There is additional information needed about your condition so we can match it to the FDA approval of the drug and/or studies of effectiveness.
- Navitus is responsible for handling pre-approval requests for all drugs requiring prior authorization. Cook Children's Health Plan will work with Navitus and your provider to gather the information needed.
What if I can't get the medication my doctor ordered approved?
If your doctor cannot be reached to approve a prescription, you may be able to get a three-day emergency supply of your medication. Please call Member Services for help with your medications or refills.
What is a drug formulary?
The formulary is a list of brand name and generic drugs available in your plan. It is a guide for doctors to know which drugs are covered. You can use the searchable formulary to search for drugs by name or type (class).
What is a clinical edit?
Clinical edits are rules that let us review a member's medical and drug claims history. The Texas VDP sets the criteria for clinical edits. If a patient does not meet the guidelines, then pre-approval will be required. If a patient does meet the guidelines, based on past medical and drug claims, the prescription will be approved without pre-approval.
Do I have any copays for my/my child's prescription drugs?
Some CHIP members may have a copay. Check the front of your member ID card for your copay amounts. If you have not received your ID card, please call Member Services to request one at 1-800-964-2247.
You may also view your Member ID card on your MyCookChildren's member portal account. To access your account or to set up an account, click https://mycookchildrens.cookchp.org/.
Prescription copays do not apply to:
- CHIP Perinate Newborn
- CHIP Perinatal
- CHIP Members that are Native Americans or Alaskan Natives
- STAR/Medicaid Members
· If you do not see your medicine listed in the formulary, you may ask for an exception at CCHPMemberAdvocate@cookchildrens.org. Please tell us the reason why this medicine should be covered. When we receive your exception request, one of our member advocates will contact you to get more information.
You can also call Member Services to ask for a hard copy of the formulary mailed to you at no cost.