For pharmacy staff, prescribing providers, managed care organization (MCO) staff, drug manufacturers, and the general public to request expedited formulary coverage, an expedited preferred drug list change, or notify HHSC about potential drug shortages impacting prescribing choice and pharmacy claims processing.
Backorder, allocation, or drugs in short supply may have a continual adverse impact on people enrolled in Medicaid if not resolved in a timely manner. The form provides space for alternative recommendations with the supply chain in mind to address formulary request changes and drug shortages. Providing more information on the form assists HHSC to determine an appropriate plan of action.
When to Prepare or Update
To request expedited formulary coverage, an expedited preferred drug list change, or notify HHSC about drug shortages impacting prescribing choice and pharmacy claim processing.
- Stakeholder Information: Include your name, organization, and email address. Make sure to include whether you are at the pharmacy level, corporate level, provider level, MCO level, manufacturer level, or other professional organizations.
- Drug Information: Be specific about strengths, dosage forms, and include all national drug codes (NDCs) impacted by the drug shortage or for the expedited formulary or preferred drug list status change.
- Drug Shortage and Expedited Formulary or Preferred Drug List Change Request Information:
- Drug Shortages:
- Reason for Reporting a Drug Shortage: Is the shortage due to a backorder, allocation, short supply, recall, discontinuation by the manufacturer or another reason?
- Extent of Shortage: Is the impact local, wholesaler, statewide, nationwide or another reason?
- Estimated Length of Issue: What is the estimated time frame of the shortage? What are your sources of information? Are they website links, email with manufacturer or something else?
- Drug Information: Has the shortage been verified with FDA, ASHP, drug manufacturer, or any other resources? Include website links, verification date, or manufacturer contact information if applicable.
- Formulary Additions or Preferred Drug List Status Changes
- Formulary Addition or Preferred Drug List (PDL) Status Change: Is the request for a drug addition to the formulary? Is the request to recommend a change in the PDL status of a drug? Provide a rationale for the request of a PDL status change.
- Product NDC change: Did the manufacturer change the drug’s NDC or did the drug’s NDC change for other reasons? Include the discontinued and new NDC.
- Alternatives: Provide alternative drug (and NDC) suggestions and recommendations for formulary addition.
- Drug Shortages:
- Fax: 512-491-1962
- Email: firstname.lastname@example.org
Email questions about this form to the Vendor Drug Program at email@example.com.