| (a) A doctor providing care to an injured employee
shall prescribe for the employee medically necessary prescription
drugs and over-the-counter medication (OTC) alternatives as clinically
appropriate and applicable in accordance with applicable state law
and as provided by this section.
(1) It shall be indicated on the prescription that
the prescription is related to a workers' compensation claim.
(2) When prescribing an OTC medication alternative
to a prescription drug, the doctor shall indicate on the prescription
the appropriate strength of the medication and the approximate quantity
of the OTC medication that is reasonably required by the nature of
the compensable injury.
(3) The doctor shall prescribe generic prescription
drugs when available and clinically appropriate. If in the medical
judgment of the prescribing doctor a brand-name drug is necessary,
the doctor must specify on the prescription that brand-name drugs
be dispensed in accordance with applicable state and federal law,
and must maintain documentation justifying the use of the brand-name
drug, in the patient's medical record.
(4) The doctor shall prescribe OTC medications in lieu
of a prescription drug when clinically appropriate.
(b) When prescribing, the doctor shall prescribe in
accordance with §134.530 and §134.540 of this title (relating
to Requirements for Use of the Closed Formulary for Claims Not Subject
to Certified Networks and Requirements for Use of the Closed Formulary
for Claims Subject to Certified Networks, respectively).
(c) The pharmacist shall dispense no more than a 90-day
supply of a prescription drug.
(d) Pharmacies and pharmacy processing agents shall
submit bills for pharmacy services in accordance with Chapter 133
(relating to General Medical Provisions) and Chapter 134 (relating
to Benefits--Guidelines for Medical Services, Charges, and Payments.
(1) Health care providers shall bill using national
drug codes (NDC) when billing for prescription drugs.
(2) Compound drugs shall be billed by listing each
drug included in the compound and calculating the charge for each
drug separately.
(3) A pharmacy may contract with a separate person
or entity to process bills and payments for a medical service; however,
these entities are subject to the direction of the pharmacy and the
pharmacy is responsible for the acts and omissions of the person or
entity. Except as allowed by Labor Code §413.042, the injured
employee shall not be billed for pharmacy services.
(e) The insurance carrier, injured employee, or pharmacist
may request a statement of medical necessity from the prescribing
doctor. If an insurance carrier requests a statement of medical necessity,
the insurance carrier shall provide the sender of the bill a copy
of the request at the time the request is made. An insurance carrier
shall not request a statement of medical necessity unless in the absence
of such a statement the insurance carrier could reasonably support
a denial based upon extent of, or relatedness to the compensable injury,
or based upon an adverse determination.
(f) The prescribing doctor shall provide a statement
of medical necessity to the requesting party no later than the 14th
day after receipt of request. The prescribing doctor shall not bill
for nor shall the insurance carrier reimburse for the statement of
medical necessity.
(g) In addition to the requirements of §133.240
of this title (relating to Medical Payments and Denials) regarding
explanation of benefits (EOB), at the time an insurance carrier denies
payment for medications for any reason related to compensability of,
liability for, extent of, or relatedness to the compensable injury,
or for reasons related to an adverse determination, the insurance
carrier shall also send the EOB to the injured employee, and the prescribing
doctor.
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| Source Note: The provisions of this §134.502 adopted to be effective January 3, 2002, 26 TexReg 10970; amended to be effective January 1, 2003, 27 TexReg 12353; amended to be effective March 30, 2014, 39 TexReg 2102 |
