Texas Register, Volume 38, Number 26, Pages 4053-4242, June 28, 2013 Page: 4,071
4053-4242 p. ; 28 cm.View a full description of this periodical.
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with any pharmacy provider that meets the health care MCO's cre-
dentialing requirements, and agrees to the health care MCO's financial
terms and other reasonable administrative and professional terms.
(e) A health care MCO can enter into selective pharmacy
provider agreements for specialty drugs, as defined in 354.1853
of this title (relating to Specialty Drugs), subject to the following
limitations:
(1) A health care MCO is prohibited from entering into an
exclusive contract for specialty drugs with a pharmacy owned in full
or part by a pharmacy benefits manager contracted with the health care
MCO.
(2) The selective contracting agreement cannot require the
pharmacy provider to contract exclusively with the health care MCO.
(3) A health care MCO cannot require a member to obtain
a specialty drug from a mail-order pharmacy.
(f) A health care MCO must allow pharmacy providers to fill
prescriptions for covered outpatient drugs ordered by any licensed pre-
scriber regardless of the prescriber's network participation.
(g) A health care MCO must pay claims in accordance with
Texas Insurance Code 843.339, relating to prescription drug claims
payment requirements.
(h) A health care MCO must comply with 533.005(a)(23)(K)
and (a-2) of the Government Code with respect to maximum allowable
cost (MAC) lists.
(i) [(h)] A health care [An] MCO must comply with the rules in
Chapter 354, Subchapter F (relating to Pharmacy Services) [and Sub-
chapter W (relating to Pharmacy Limitations)] of this title with the ex-
ception of:
{(4) Section 3541865( relatingo Numbere prescriptions
bimitJ)},
(1) [(2)] Section 354.1867 (relating to Refills);
(2) [(3)] Section 354.1873 (relating to Freedom of Choice);
(3) Section 354.1877 (relating to Quantity Limitations);
and
(4) Division 6 (relating to Pharmacy Claims).[; and]
5 Stion m 35447 (relating to Quantity f~ imitations)
(j) A health care MCO must require its subcontractors to com-
ply with the requirements of this subchapter when providing outpatient
pharmacy benefits through Medicaid managed care.
353.907. Prior 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 consid-
ered 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 cov-
ered 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 re-
quest 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 au-
thorization by telephone, fax, or electronic communications throughthe 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-pre-
ferred 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 clinicall 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.
(i) A health care MCO must accept a standard prior authoriza-
tion form for a covered outpatient drug in accordance with Texas In-
surance Code Chapter 1369, Subchapter F.
353.913. Managed Care Organization Requirements Concerning
Out-of-Network Outpatient Pharmacy Services.
(a) Network adequacy.
(1) The Health and Human Services Commission (HHSC)
is the state agency responsible for overseeing and monitoring the Med-
icaid managed care program. A health care managed care organization
(health care MCO) participating in the Medicaid managed care pro-
gram must offer a network of pharmacy providers that is sufficient to
meet the needs of the health care MCO's members. HHSC will mon-
itor health care MCO members' access to an adequate provider net-
work through reports from the health care MCOs and complaints re-
ceived from providers and members. The reporting requirements are
discussed in subsection (c) of this section.
(2) A health care MCO may not refuse to reimburse an
out-of-network pharmacy provider for emergency covered outpatient
pharmacy services.
(b) Reasonable reimbursement methodology. If a health care
MCO and an out-of-network pharmacy provider cannot agree on a re-
imbursement amount, then the health care MCO must reimburse the
provider at the usual and customary rate that prevails in the service
area, unless payment is limited by state or federal law.
(c) Reporting requirements. A health care MCO must submit
a quarterly report to HHSC regarding out-of-network pharmacy
utilization, as described in 353.4 of this chapter (relating to Man-
aged Care Organization Requirements Concerning Out-of-Network
Providers). For purposes of such reporting, the health care MCO will
include out-of-network pharmacy utilization under the "other services"
category.
(d) Utilization.
(1) Upon review of a report described in subsection (c) of
this section, HHSC may determine that a health care MCO exceeded
maximum out-of-network usage standards set by HHSC for out-of-net-
work access to covered outpatient pharmacy services during the report-
ing period.
(2) Out-of-network usage standards. No more than 20 per-
cent of total dollars billed to a health care MCO for covered outpatient
pharmacy services may be billed by out-of-network providers.
(e) Provider complaints.PROPOSED RULES June 28, 2013 38 TexReg 4071
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Texas. Secretary of State. Texas Register, Volume 38, Number 26, Pages 4053-4242, June 28, 2013, periodical, June 28, 2013; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth313178/m1/19/: accessed April 19, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.