Texans can dial 2-1-1 (option 6) for information on COVID-19 and local community resources on health care, utilities, food, housing and more. More COVID-19 information.
Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
If still having trouble viewing or downloading a form, click here.
For pharmacy staff, managed care organization staff or pharmacy stakeholders to report significant drug shortages that will have continuing adverse impact on people enrolled in Medicaid if not resolved in a timely manner. Form provides space for the recommendation of an alternative with supply chain in mind so extra demand will not cause another shortage.
When to Prepare or Update
To notify requestors of a drug shortage and recommend an alternative.
- Reporter Information: make sure to include whether you are at pharmacy level, corporate level, or other professional organizations, etc.
- Drug Information: be specific about strength and dosage forms and include all that have been affected by the shortage.
- Shortage information:
- Reason for Reporting: is the shortage due to a recall, discontinuation by the manufacturer or another reason?
- Extent of Shortage: local, wholesaler, statewide, nationwide, etc.
- Estimated Length of Issue Timeline: how long do you think the shortage will continue?
- Product Status Change: did the manufacturer introduced same drug under different NDC or another manufacturer re-patent it with different NDC and packaging, etc.?
- Alternative: please suggest drugs (and NDCs) that can be a bridge alternate or replace the drug.Make sure that extra demand will not cause shortage of this drug.
- Published Notices: did you verify with FDA, ASHP, or any other resource as to whether this shortage was announced on their website?Please include link to website and date when verified.
- Fax: 512-491-1962
- Email: firstname.lastname@example.org
Questions about this form should be directed to the VDP Pharmacy Benefits Access Help Desk at 800-435-4165.