| (a) A doctor providing care to an injured employee
must prescribe for the employee medically necessary prescription drugs
and over-the-counter medication alternatives as clinically appropriate
and applicable in accordance with applicable state law and as provided
by this section.
(1) The doctor must indicate on the prescription that
the prescription is related to a workers' compensation claim.
(2) When prescribing an over-the-counter medication
alternative to a prescription drug, the doctor must indicate on the
prescription the appropriate strength of the medication and the approximate
quantity of the over-the-counter medication that is reasonably required
by the nature of the compensable injury.
(3) The doctor must 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 must prescribe over-the-counter medications
instead of a prescription drug when clinically appropriate.
(b) When prescribing, the doctor must prescribe in
accordance with §134.530 and §134.540 of this title (Closed
Formulary for Claims Not Subject to Certified Networks and Closed
Formulary for Claims Subject to Certified Networks, respectively).
(c) The pharmacist must dispense no more than a 90-day
supply of a prescription drug.
(d) Pharmacies and pharmacy processing agents must
submit bills for pharmacy services in accordance with Chapter 133
(General Medical Provisions) and Chapter 134 (Benefits--Guidelines
for Medical Services, Charges, and Payments).
(1) Health care providers must bill using national
drug codes (NDC) when billing for prescription drugs.
(2) Compound drugs must 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.
(4) Except as allowed by Labor Code §413.042,
the injured employee must 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.
(1) If an insurance carrier requests a statement of
medical necessity, the insurance carrier must provide the sender of
the bill a copy of the request at the time the request is made.
(2) An insurance carrier must not request a statement
of medical necessity unless in the absence of such a statement the
insurance carrier could reasonably support a denial based on extent
of, or relatedness to, the compensable injury or based on an adverse
determination.
(f) The prescribing doctor must provide a statement
of medical necessity to the requesting party no later than the 14th
day after receiving the request. The prescribing doctor must not bill
for, and the insurance carrier must not reimburse for, the statement
of medical necessity.
(g) In addition to the requirements of §133.240
of this title (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 must 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; amended to be effective November 28, 2024, 49 TexReg 9758 |
