| (a) Form requirements. The commissioner adopts by reference
the Prior Authorization Request Form for Prescription Drug Benefits
form, to be accepted and used by an issuer in compliance with subsection
(b) of this section. The form and its instruction sheet are on TDI's
website at www.tdi.texas.gov/forms/form10.html; or the form and its
instruction sheet can be requested by mail from the Texas Department
of Insurance, Rate and Form Review Office, MC: LH-MCQA, PO Box 12030,
Austin, Texas 78711-2030. The form must be reproduced without changes.
The form provides space for the following information:
(1) the name of the issuer or the issuer's agent that
manages prescription drug benefits, telephone number, and fax number;
(2) the date the request is submitted;
(3) a place to request an expedited or urgent review
if the prescribing provider or the prescribing provider's designee
certifies that applying the standard review time frame may seriously
jeopardize the life or health of the patient or the patient's ability
to regain maximum function;
(4) the patient's name, contact telephone number, date
of birth, sex, address, and identifying insurance information;
(5) the prescribing provider's name, NPI number, specialty,
telephone and fax numbers, address, and contact person's name and
telephone number;
(6) for a prescription drug:
(A) drug name;
(B) strength;
(C) route of administration;
(D) quantity;
(E) number of days' supply;
(F) expected therapy duration; and
(G) to the best of the prescribing provider's knowledge,
whether the medication is:
(i) a new therapy; or
(ii) continuation of therapy, and if so, to the best
of the prescribing provider's knowledge:
(I) the approximate date therapy was initiated;
(II) whether the patient is adhering to the drug therapy
regimen; and
(III) whether the drug therapy regimen is effective;
(7) for a provider administered drug, the HCPCS code,
NDC number, and dose per administration;
(8) for a prescription compound drug, its name, ingredients,
and each ingredient's NDC number and quantity;
(9) for a prescription device, its name, expected duration
of use, and, if applicable, its HCPCS code;
(10) the patient's clinical information, including:
(A) diagnosis, ICD version number (if more than one
version is allowed by the U.S. Department of Health and Human Services),
and ICD code;
(B) to the best of the prescribing provider's knowledge,
the drugs the patient has taken for this diagnosis, including:
(i) drug name, strength, and frequency;
(ii) the approximate dates or duration the drugs were
taken; and
(iii) patient's response, reason for failure, or allergic
reaction;
(C) the patient's drug allergies, if any; and
(D) the patient's height and weight, if relevant;
(11) a list of relevant lab tests, and their dates
and values;
(12) a place for the prescribing provider to:
(A) include pertinent clinical information to justify
requests for initial or ongoing therapy, or increases in current dosage,
strength, or frequency;
(B) explain any comorbid conditions and contraindications
for formulary drugs; or
(C) provide details regarding titration regimen or
oncology staging, if applicable; and
(13) a directive to the prescribing provider stating
that:
(A) for a request for prior authorization of continuation
of therapy (other than a request for a step-therapy exception as provided
in subparagraph (B) of this paragraph), it is not necessary to complete
the sections of the form regarding patient clinical information and
justification for the therapy unless there has been a material change
in the information previously provided; and
(B) for a request for a step-therapy exception, the
section of the form regarding justification for the step-therapy exception
must be completed.
(b) Acceptance and use of the form.
(1) If a prescribing provider submits the form to request
prior authorization of a prescription drug benefit for which the issuer's
plan requires prior authorization, the issuer must accept and use
the form for that purpose. An issuer may also have on its website
another electronic process a prescribing provider may use to request
prior authorization of a prescription drug benefit.
(2) This form may be used by a prescribing provider
to request prior authorization of:
(A) a prescription drug;
(B) a prescription device;
(C) formulary exceptions;
(D) quantity limit overrides; and
(E) step-therapy requirement exceptions.
(3) This form may not be used by a prescribing provider
to:
(A) request an appeal;
(B) confirm eligibility;
(C) verify coverage;
(D) ask whether a prescription drug or device requires
prior authorization; or
(E) request prior authorization of a health care service.
(c) Effective date. An issuer must accept a request
for prior authorization of prescription drug benefits made by a prescribing
provider using the form on or after the effective date of this section.
An issuer must accept a request using the form that was in place prior
to the effective date of this section for 90 days after the effective
date.
(d) Availability of the form.
(1) A health benefit plan issuer must make the form
available electronically on its website.
(2) A health benefit plan issuer's agent that manages
or administers prescription drug benefits must make the form available
electronically on its website.
|
