The following words and terms, when used in this subchapter,
have the following meaning unless the context clearly indicates otherwise.
(1) Clinical prior authorization (clinical PA)--A review
process authorized by HHSC that is conducted by a healthcare managed
care organization (health care MCO) prior to dispensing a drug. All
clinical PAs must be identified on the Medicaid Vendor Drug Program
website at http://www.txvendordrug.com.
(2) Covered outpatient drug--A drug or biological product
included on the formulary and provided in an outpatient setting.
(3) Formulary--The list of covered outpatient drugs
for the Texas Medicaid program.
(4) Maximum allowable cost--The highest unit price
set by a health care MCO, or its subcontractor, for reimbursement
of therapeutically equivalent multi-source drugs.
(5) Network provider--A pharmacy provider who has entered
into a contract with the health care MCO to provide outpatient drug
benefits to Medicaid enrollees.
(6) Non-preferred drug--A covered outpatient drug on
the preferred drug list (PDL) that has been designated as non-preferred.
(7) Pharmacy benefits manager (PBM)--An entity that
administers the Medicaid outpatient drug benefit on behalf of a health
(8) Preferred drug--A covered outpatient drug on the
PDL that has been designated as preferred because it has been evaluated
to be safe, clinically effective, and cost-effective compared to other
drugs in the same therapeutic drug class on the market.
(9) Preferred drug list (PDL)--The list of covered
outpatient drugs reviewed by the Drug Utilization Review Board (DUR
Board). Reviewed drugs are recommended by the DUR Board as either
preferred or non-preferred and HHSC establishes the final designation.
(10) Preferred drug list prior authorization (PDL PA)--A
review conducted by a health care MCO prior to dispensing a non-preferred
|Source Note: The provisions of this §353.903 adopted to be effective March 1, 2012, 37 TexReg 1292; amended to be effective September 1, 2013, 38 TexReg 5429; amended to be effective February 9, 2016, 41 TexReg 960