|(a) A health care managed care organization (health
care MCO) must adopt and exclusively use the Health and Human Services
Commission's (HHSC's) Medicaid formulary and preferred drug list.
(b) A health care MCO is not authorized to negotiate
rebates for covered outpatient drugs with drug manufacturers, or to
receive confidential drug pricing regarding covered outpatient drugs
from drug manufacturers.
(c) A health care MCO cannot pay claims submitted by
a pharmacy provider who is under sanction or exclusion from the Medicaid
or CHIP Programs.
(d) Except as provided in subsection (e) of this section,
a health care MCO must enter into a network provider agreement with
any pharmacy provider that meets the health care MCO's credentialing
requirements, and agrees to the health care MCO's financial terms
and other reasonable administrative and professional terms.
(e) A health care MCO can enter into selective pharmacy
provider agreements for specialty drugs, as defined in §354.1853
of this title (relating to Specialty Drugs), subject to the following
(1) A health care MCO is prohibited from entering into
an exclusive contract for specialty drugs with a pharmacy owned in
full or part by a pharmacy benefits manager contracted with the health
(2) The selective contracting agreement cannot require
the pharmacy provider to contract exclusively with the health care
(3) A health care MCO cannot require a member to obtain
a specialty drug from a mail-order pharmacy.
(f) A health care MCO must allow pharmacy providers
to fill prescriptions for covered outpatient drugs ordered by any
licensed prescriber regardless of the prescriber's network participation.
(g) A health care MCO must pay claims in accordance
with Texas Insurance Code §843.339, relating to prescription
drug claims payment requirements.
(h) A health care MCO must comply with §533.005(a)(23),
(a-1), and (a-2) of the Government Code related to outpatient pharmacy
benefit requirements in Medicaid managed care.
(i) A health care MCO must comply with the rules in
Chapter 354, Subchapter F (relating to Pharmacy Services) of this
title with the exception of:
(1) Section 354.1867 (relating to Refills);
(2) Section 354.1873 (relating to Freedom of Choice);
(3) Section 354.1877 (relating to Quantity Limitations);
(4) Division 6 (relating to Pharmacy Claims).
(j) A health care MCO must require its subcontractors
to comply with the requirements of this subchapter when providing
outpatient pharmacy benefits through Medicaid managed care.