|(a) A health care managed care organization (health
care MCO) may not impose a preferred drug list prior authorization
(PDL PA) on a covered outpatient drug before the drug has been considered
at a meeting of the Health and Human Services Commission's (HHSC's)
Drug Utilization Review Board.
(b) A health care MCO may not impose a PDL PA on a
covered outpatient drug that was prescribed before HHSC's designation
of the drug as non-preferred, unless the member has exhausted all
of the prescription, including any authorized refills.
(c) A health care MCO must allow a provider to submit
a request for prior authorization of a covered outpatient drug by
telephone, fax, or electronic communications through the Internet.
(d) A health care MCO must respond to a request for
prior authorization by telephone, fax, or electronic communications
through the Internet no later than 24 hours after receiving the request.
If the health care MCO cannot respond to the prior authorization request
within this time, then the health care MCO must allow a pharmacy to
dispense a 72-hour supply of the prescribed drug.
(e) A health care MCO cannot require a PDL PA for a
(f) A health care MCO must require a PDL PA for a non-preferred
(g) If a member's medical condition does not match
the health care MCO's clinical criteria for dispensing a covered outpatient
drug, the health care MCO may require a clinical PA for a preferred
or non-preferred drug.
(h) HHSC will post on its website clinical PAs that
are used in HHSC's fee-for-service Vendor Drug Program. A health care
MCO must implement all clinical PAs that HHSC has designated as "mandatory"
for the Medicaid managed care programs.
(i) A health care MCO must accept a standard prior
authorization form for a covered outpatient drug in accordance with
Texas Insurance Code Chapter 1369, Subchapter F.
|Source Note: The provisions of this §353.907 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