28 Tex. Admin. Code § 134.502 - Pharmaceutical Services
(a) A doctor providing
care to an injured employee must prescribe for the employee medically necessary
prescription drugs and over-the-counter medication alternatives as clinically
appropriate and applicable in accordance with applicable state law and as
provided by this section.
(1) The doctor must
indicate on the prescription that the prescription is related to a workers'
compensation claim.
(2) When
prescribing an over-the-counter medication alternative to a prescription drug,
the doctor must indicate on the prescription the appropriate strength of the
medication and the approximate quantity of the over-the-counter medication that
is reasonably required by the nature of the compensable injury.
(3) The doctor must prescribe generic
prescription drugs when available and clinically appropriate. If in the medical
judgment of the prescribing doctor a brand-name drug is necessary, the doctor
must specify on the prescription that brand-name drugs be dispensed in
accordance with applicable state and federal law, and must maintain
documentation justifying the use of the brand-name drug, in the patient's
medical record.
(4) The doctor must
prescribe over-the-counter medications instead of a prescription drug when
clinically appropriate.
(b) When prescribing, the doctor must
prescribe in accordance with §
134.530 and §
134.540 of this title (Closed
Formulary for Claims Not Subject to Certified Networks and Closed Formulary for
Claims Subject to Certified Networks, respectively).
(c) The pharmacist must dispense no more than
a 90-day supply of a prescription drug.
(d) Pharmacies and pharmacy processing agents
must submit bills for pharmacy services in accordance with Chapter 133 (General
Medical Provisions) and Chapter 134 (Benefits--Guidelines for Medical Services,
Charges, and Payments).
(1) Health care
providers must bill using national drug codes (NDC) when billing for
prescription drugs.
(2) Compound
drugs must be billed by listing each drug included in the compound and
calculating the charge for each drug separately.
(3) A pharmacy may contract with a separate
person or entity to process bills and payments for a medical service. However,
these entities are subject to the direction of the pharmacy, and the pharmacy
is responsible for the acts and omissions of the person or entity.
(4) Except as allowed by Labor Code §
413.042, the injured
employee must not be billed for pharmacy services.
(e) The insurance carrier, injured employee,
or pharmacist may request a statement of medical necessity from the prescribing
doctor.
(1) If an insurance carrier requests
a statement of medical necessity, the insurance carrier must provide the sender
of the bill a copy of the request at the time the request is made.
(2) An insurance carrier must not request a
statement of medical necessity unless in the absence of such a statement the
insurance carrier could reasonably support a denial based on extent of, or
relatedness to, the compensable injury or based on an adverse
determination.
(f) The
prescribing doctor must provide a statement of medical necessity to the
requesting party no later than the 14th day after receiving the request. The
prescribing doctor must not bill for, and the insurance carrier must not
reimburse for, the statement of medical necessity.
(g) In addition to the requirements of §
133.240 of this title (Medical
Payments and Denials) regarding explanation of benefits (EOB), at the time an
insurance carrier denies payment for medications for any reason related to
compensability of, liability for, extent of, or relatedness to the compensable
injury, or for reasons related to an adverse determination, the insurance
carrier must also send the EOB to the injured employee and the prescribing
doctor.
Notes
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