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RULE §354.1832Prior Authorization Procedures

(a) Requests for prior authorization. Except as provided in subsection (b) of this section, a health care practitioner who prescribes a drug that is not included on the Preferred Drug List (PDL) for a Medicaid recipient must request prior authorization of the drug to the Health and Human Services Commission (HHSC) or its designee. Specific procedures for the submission of requests for prior authorization are available on HHSC's web site. A health care practitioner may request a printed copy of the procedures and forms from HHSC.

(b) New Medicaid recipients. The PDL-related prior authorization requirement of this section does not apply if the prescription for the non-preferred drug is for a newly enrolled Medicaid recipient, until the 31st calendar day after the date of the recipient's Medicaid eligibility determination.

(c) Special Considerations. When HHSC determines based on clinical considerations, cost considerations, or guidance from the Drug Utilization Review Board that the prior authorization requirement could adversely impact Medicaid recipients' health or safety, it may be administratively more efficient to deem the approved prior authorization for a particular client for a certain period of time, or for an indefinite period.

(d) Disposition of requests for prior authorization. HHSC or its designee will notify the requesting practitioner of the approval or disapproval of the request within 24 hours of the receipt of the request.

(e) Emergency requests for prior authorization. HHSC will authorize up to a 72-hour supply of a product subject to prior authorization if:

  (1) The prescribing practitioner notifies HHSC of an emergency need for the product when submitting the request for prior authorization; and

  (2) HHSC or its designee is unable to provide its approval or disapproval within 24 hours following the receipt of the request.

Source Note: The provisions of this §354.1832 adopted to be effective November 16, 2003, 28 TexReg 9802; amended to be effective May 1, 2014, 39 TexReg 3391; amended to be effective February 9, 2016, 41 TexReg 960

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