Texas Register

TITLE 28 INSURANCE
PART 2TEXAS WORKERS' COMPENSATION COMMISSION
CHAPTER 134BENEFITS--GUIDELINES FOR MEDICAL SERVICES, CHARGES AND PAYMENTS
SUBCHAPTER FPHARMACEUTICAL BENEFITS
RULE §134.502Pharmaceutical Services
ISSUE 08/31/2001
ACTION Proposed
Preamble Texas Admin Code Rule

(a)A doctor providing care to an injured employee shall prescribe for the employee necessary prescription drugs and over-the-counter medication (OTC) alternatives as clinically appropriate and applicable in accordance with applicable state law and as provided by this section.

  (1)It shall be indicated on the prescription that the prescription is related to a workers' compensation claim.

  (2)When prescribing an OTC alternative to a prescription drug, the doctor shall indicate on the prescription the appropriate strength of the medication and the approximate quantity of the OTC medication that is reasonably required by the nature of the compensable injury.

  (3)The doctor shall 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 shall prescribe OTC medications in lieu of a prescription drug when clinically appropriate.

(b)When prescribing, the doctor shall comply with the formulary adopted by the commission.

(c)The pharmacist shall dispense no more than a 30-day supply of a prescription drug.

(d)Health care providers shall submit bills for pharmacy services in accordance with commission Rule 134.800 (d).

  (1)Health care providers shall bill using national drug codes (NDC) when billing for prescription drugs.

  (2)Compound drugs shall 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 Texas Labor Code § 413.042, the injured employee shall not be billed for pharmacy services.

(e)If an insurance carrier has questions about the relatedness of a prescription to the compensable injury or the use of brand-name prescription drugs, the carrier may request a statement of medical necessity from the prescribing doctor.

(f)The doctor shall provide a statement of medical necessity no later than the 14th working day after receipt of request. The statement of medical necessity shall include the following information:

  (1)Employee's name and social security number or TWCC number;

  (2)Cause of injury;

  (3)Employee's current condition;

  (4)Treatment, service, or medication recommended;

  (5)How treatment, service, or medication is related to the compensable injury;

  (6)Duration of treatment, service, or medication;

  (7)Expected outcome; and,

  (8)Reasons for prescribing brand name prescription drug, if applicable.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on August 20, 2001

TRD-200104908

Susan Cory

General Counsel

Texas Workers' Compensation Commission

Earliest possible date of adoption: September 30, 2001

For further information, please call: (512) 804-4287



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