1 Tex. Admin. Code § 353.907 - Prior Authorization Requirements
(a) A health care managed care organization
(health care MCO) may not impose a preferred drug list prior authorization (PDL
PA) on a covered outpatient drug before the drug has been considered at a
meeting of the Health and Human Services Commission's (HHSC's) Drug Utilization
Review Board.
(b) A health care MCO
may not impose a PDL PA on a covered outpatient drug that was prescribed before
HHSC's designation of the drug as non-preferred, unless the member has
exhausted all of the prescription, including any authorized refills.
(c) A health care MCO must allow a provider
to submit a request for prior authorization of a covered outpatient drug by
telephone, fax, or electronic communications through the Internet.
(d) A health care MCO must respond to a
request for prior authorization by telephone, fax, or electronic communications
through the Internet no later than 24 hours after receiving the request. If the
health care MCO cannot respond to the prior authorization request within this
time, then the health care MCO must allow a pharmacy to dispense a 72-hour
supply of the prescribed drug.
(e)
A health care MCO cannot require a PDL PA for a preferred drug.
(f) A health care MCO must require a PDL PA
for a non-preferred drug.
(g) If a
member's medical condition does not match the health care MCO's clinical
criteria for dispensing a covered outpatient drug, the health care MCO may
require a clinical PA for a preferred or non-preferred drug.
(h) HHSC will post on its website clinical
PAs that are used in HHSC's fee-for-service Vendor Drug Program. A health care
MCO must implement all clinical PAs that HHSC has designated as "mandatory" for
the Medicaid managed care programs.
(i) A health care MCO must accept a standard
prior authorization form for a covered outpatient drug in accordance with Texas
Insurance Code Chapter 1369, Subchapter F.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.