Text of subsection effective until April 01, 2025

(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 § 531.072, except for any drug exempted from prior authorization requirements by federal law and except as provided by Subsections (a-3) and (j). 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 § 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.

Text of subsection effective until April 01, 2025

(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.

Text of subsection effective until April 01, 2025

(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.

Text of subsection effective until April 01, 2025

(a-3) The executive commissioner, in the rules and standards governing the vendor drug program, may not require prior authorization for a nonpreferred antipsychotic drug that is included on the vendor drug formulary and prescribed to an adult patient if:
(1) during the preceding year, the patient was prescribed and unsuccessfully treated with a 14-day treatment trial of an antipsychotic drug that is included on the appropriate preferred drug list adopted under § 531.072 and for which a single claim was paid;
(2) the patient has previously been prescribed and obtained prior authorization for the nonpreferred antipsychotic drug and the prescription is for the purpose of drug dosage titration; or
(3) subject to federal law on maximum dosage limits and commission rules on drug quantity limits, the patient has previously been prescribed and obtained prior authorization for the nonpreferred antipsychotic drug and the prescription modifies the dosage, dosage frequency, or both, of the drug as part of the same treatment for which the drug was previously prescribed.

Text of subsection effective until April 01, 2025

(a-4) Subsection (a-3) does not affect:
(1) the authority of a pharmacist to dispense the generic equivalent or interchangeable biological product of a prescription drug in accordance with Subchapter A, Chapter 562, Occupations Code;
(2) any drug utilization review requirements prescribed by state or federal law; or
(3) clinical prior authorization edits to preferred and nonpreferred antipsychotic drug prescriptions.

Text of subsection effective until April 01, 2025

(a-5) The executive commissioner, in the rules and standards governing the vendor drug program and as part of the requirements under a contract between the commission and a Medicaid managed care organization, shall:
(1) require, to the maximum extent possible based on a pharmacy benefit manager’s claim system, automation of clinical prior authorization for each drug in the antipsychotic drug class; and
(2) ensure that, at the time a nonpreferred or clinical prior authorization edit is denied, a pharmacist is immediately provided a point-of-sale return message that:
(A) clearly specifies the contact and other information necessary for the pharmacist to submit a prior authorization request for the prescription; and
(B) instructs the pharmacist to dispense, only if clinically appropriate under federal or state law, a 72-hour supply of the prescription.