(a) The executive commissioner, in the rules and standards governing the Medicaid vendor drug program and the child health plan program, shall require prior authorization for the reimbursement of a drug that is not included in the appropriate preferred drug list adopted under Section 531.072, except for any drug exempted from prior authorization requirements by federal law. The executive commissioner may require prior authorization for the reimbursement of a drug provided through any other state program administered by the commission or a state health and human services agency, including a community mental health center and a state mental health hospital if the commission adopts preferred drug lists under Section 531.072 that apply to those facilities and the drug is not included in the appropriate list. The executive commissioner shall require that the prior authorization be obtained by the prescribing physician or prescribing practitioner.
(a-1) Until the commission has completed a study evaluating the impact of a requirement of prior authorization on recipients of certain drugs, the executive commissioner shall delay requiring prior authorization for drugs that are used to treat patients with illnesses that:
(1) are life-threatening;
(2) are chronic; and
(3) require complex medical management strategies.
Terms Used In Texas Government Code 531.073
- Person: includes corporation, organization, government or governmental subdivision or agency, business trust, estate, trust, partnership, association, and any other legal entity. See Texas Government Code 311.005
(a-2) Not later than the 30th day before the date on which prior authorization requirements are implemented, the commission shall post on the Internet for consumers and providers:
(1) a notification of the implementation date; and
(2) a detailed description of the procedures to be used in obtaining prior authorization.
(b) The commission shall establish procedures for the prior authorization requirement under the Medicaid vendor drug program to ensure that the requirements of 42 U.S.C. Section 1396r-8(d)(5) and its subsequent amendments are met. Specifically, the procedures must ensure that:
(1) a prior authorization requirement is not imposed for a drug before the drug has been considered at a meeting of the Drug Utilization Review Board under Section 531.0736;
(2) there will be a response to a request for prior authorization by telephone or other telecommunications device within 24 hours after receipt of a request for prior authorization; and
(3) a 72-hour supply of the drug prescribed will be provided in an emergency or if the commission does not provide a response within the time required by Subdivision (2).
(c) The commission shall ensure that a prescription drug prescribed before implementation of a prior authorization requirement for that drug for a recipient under the child health plan program, Medicaid, or another state program administered by the commission or a health and human services agency or for a person who becomes eligible under the child health plan program, Medicaid, or another state program administered by the commission or a health and human services agency is not subject to any requirement for prior authorization under this section unless the recipient has exhausted all the prescription, including any authorized refills, or a period prescribed by the commission has expired, whichever occurs first.
(d) The commission shall implement procedures to ensure that a recipient under the child health plan program, Medicaid, or another state program administered by the commission or a person who becomes eligible under the child health plan program, Medicaid, or another state program administered by the commission or a health and human services agency receives continuity of care in relation to certain prescriptions identified by the commission.
(e) The commission may by contract authorize a private entity to administer the prior authorization requirements imposed by this section on behalf of the commission.
(f) The commission shall ensure that the prior authorization requirements are implemented in a manner that minimizes the cost to the state and any administrative burden placed on providers.
(g) The commission shall ensure that requests for prior authorization may be submitted by telephone, facsimile, or electronic communications through the Internet.
(h) The commission shall provide an automated process that may be used to assess a Medicaid recipient’s medical and drug claim history to determine whether the recipient’s medical condition satisfies the applicable criteria for dispensing a drug without an additional prior authorization request.
(i) Repealed by Acts 2013, 83rd Leg., R.S., Ch. 1312, Sec. 99(17), eff. September 1, 2013.