Text of section effective on April 01, 2025
Sec. 549.0257.  PRIOR AUTHORIZATION PROCEDURES.  (a)  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) are met.  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 Subchapter G;
(2)  a response to a request for prior authorization is provided by telephone or other telecommunications device within 24 hours after receipt of the request; and
(3)  a 72-hour supply of the drug prescribed is provided in an emergency or if the commission does not provide a response within the period required by Subdivision (2).
(b)  The commission shall implement procedures to ensure that a recipient or enrollee under Medicaid, the child health plan program, or another state program the commission administers, or an individual who becomes eligible under Medicaid, the child health plan program, or another state program the commission or a health and human services agency administers, receives continuity of care in relation to certain prescriptions the commission identifies.
(c)  The commission shall ensure that requests for prior authorization may be submitted by telephone, facsimile, or electronic communications through the Internet.
(d)  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.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.