(a) Subject to Subsection (b), a contract to which this subchapter applies must require the contracting Medicaid managed care organization to develop, implement, and maintain an outpatient pharmacy benefit plan for the organization’s enrolled recipients that:
(1) except as provided by § 540.0280(2), exclusively employs the vendor drug program formulary and preserves this state’s ability to reduce Medicaid fraud, waste, and abuse;
(2) adheres to the applicable preferred drug list the commission adopts under Subchapter E, Chapter 549;
(3) except as provided by § 540.0280(1), includes the prior authorization procedures and requirements prescribed by or implemented under Sections 549.0257(a) and (c) and 549.0259 for the vendor drug program;
(4) does not require a clinical, nonpreferred, or other prior authorization for any antiretroviral drug, as defined by § 549.0252, or a step therapy or other protocol, that could restrict or delay the dispensing of the drug except to minimize fraud, waste, or abuse; and
(5) does not require prior authorization for a nonpreferred antipsychotic drug prescribed to an adult recipient if the requirements of § 549.0253(a) are met.
(b) The requirements imposed by Subsections (a)(1)-(3) do not apply, and may not be enforced, on and after August 31, 2023.

Text of section effective on April 01, 2025