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 12/28/2001
ACTION Final/Adopted
Preamble Texas Admin Code Rule

(a)A doctor providing care to an injured employee shall prescribe for the employee medically 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 medication 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 choose medications and drugs from the formulary adopted by the commission.

(c)The pharmacist shall dispense no more than a 90-day supply of a prescription drug.

(d)Pharmacists shall submit bills for pharmacy services in accordance with §134.800(d) of this title (relating to Required Billing Forms and Information).

  (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. Except as allowed by Texas Labor Code § 413.042, the injured employee shall not be billed for pharmacy services.

(e)An insurance carrier shall request a statement of medical necessity from the prescribing doctor before denying reimbursement for prescription or over the counter medications. This request shall be made in accordance with §133.301(d)-(g) of this title (relating to Retrospective Review of Medical Bills). At the time an insurance carrier sends the request for a statement of medical necessity, the carrier shall send the provider of the pharmaceutical services and the employee a copy of the request. The prescribing doctor shall not bill for nor shall the carrier reimburse for the statement of medical necessity.

(f)The employee or pharmacist may request a statement of medical necessity from the prescribing doctor.

(g)The prescribing doctor shall provide a statement of medical necessity to the requesting party no later than the 14th working day after receipt of request.

(h)At the time an insurance carrier reduces or denies payment for medications, the carrier shall send the explanation of benefits to the pharmacist, the employee, and the prescribing doctor.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on December 14, 2001

TRD-200107938

Susan Cory

General Counsel

Texas Workers' Compensation Commission

Effective date: January 3, 2002

Proposal publication date: August 31, 2001

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



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