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TITLE 1ADMINISTRATION
PART 15TEXAS HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 353MEDICAID MANAGED CARE
SUBCHAPTER JOUTPATIENT PHARMACY SERVICES
RULE §353.907Prior Authorization Requirements

(a) A health care managed care organization (health care MCO) may not impose a preferred drug list prior authorization (PDL PA) on a covered outpatient drug before the drug has been considered at a meeting of the Health and Human Services Commission's (HHSC's) Pharmaceutical and Therapeutics Committee.

(b) A health care MCO may not impose a PDL PA on a covered outpatient drug that was prescribed before HHSC's designation of the drug as non-preferred, unless the member has exhausted all of the prescription, including any authorized refills.

(c) A health care MCO must allow a provider to submit a request for prior authorization of a covered outpatient drug by telephone, fax, or electronic communications through the Internet.

(d) A health care MCO must respond to a request for prior authorization by telephone, fax, or electronic communications through the Internet no later than 24 hours after receiving the request. If the health care MCO cannot respond to the prior authorization request within this time, then the health care MCO must allow a pharmacy to dispense a 72-hour supply of the prescribed drug.

(e) A health care MCO cannot require a PDL PA for a preferred drug.

(f) A health care MCO must require a PDL PA for a non-preferred drug.

(g) If a member's medical condition does not match the health care MCO's clinical criteria for dispensing a covered outpatient drug, the health care MCO may require a clinical edit PA for a preferred or non-preferred drug.

(h) HHSC will post on its website clinical edit PAs that are used in HHSC's fee-for-service Vendor Drug Program. A health care MCO must implement all clinical edit PAs that HHSC has designated as "mandatory" for the Medicaid managed care programs.

(i) A health care MCO must accept a standard prior authorization form for a covered outpatient drug in accordance with Texas Insurance Code Chapter 1369, Subchapter F.


Source Note: The provisions of this §353.907 adopted to be effective March 1, 2012, 37 TexReg 1292; amended to be effective September 1, 2013, 38 TexReg 5429

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