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TITLE 1ADMINISTRATION
PART 15TEXAS HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 353MEDICAID MANAGED CARE
SUBCHAPTER JOUTPATIENT PHARMACY SERVICES
RULE §353.903Definitions

The following words and terms, when used in this subchapter, have the following meaning unless the context clearly indicates otherwise.

  (1) Clinical prior authorization (clinical PA)--A review process authorized by HHSC that is conducted by a healthcare managed care organization (health care MCO) prior to dispensing a drug. All clinical PAs must be identified on the Medicaid Vendor Drug Program website at http://www.txvendordrug.com.

  (2) Covered outpatient drug--A drug or biological product included on the formulary and provided in an outpatient setting.

  (3) Formulary--The list of covered outpatient drugs for the Texas Medicaid program.

  (4) Maximum allowable cost--The highest unit price set by a health care MCO, or its subcontractor, for reimbursement of therapeutically equivalent multi-source drugs.

  (5) Network provider--A pharmacy provider who has entered into a contract with the health care MCO to provide outpatient drug benefits to Medicaid enrollees.

  (6) Non-preferred drug--A covered outpatient drug on the preferred drug list (PDL) that has been designated as non-preferred.

  (7) Pharmacy benefits manager (PBM)--An entity that administers the Medicaid outpatient drug benefit on behalf of a health care MCO.

  (8) Preferred drug--A covered outpatient drug on the PDL that has been designated as preferred because it has been evaluated to be safe, clinically effective, and cost-effective compared to other drugs in the same therapeutic drug class on the market.

  (9) Preferred drug list (PDL)--The list of covered outpatient drugs reviewed by the Drug Utilization Review Board (DUR Board). Reviewed drugs are recommended by the DUR Board as either preferred or non-preferred and HHSC establishes the final designation.

  (10) Preferred drug list prior authorization (PDL PA)--A review conducted by a health care MCO prior to dispensing a non-preferred drug.


Source Note: The provisions of this §353.903 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

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