| (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 prior authorization
(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.
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