Prior Authorization for Prescription Drugs. The MCO must adopt prior authorization policies and procedures that comply with state and federal laws, including 42 U.S.C. §1369r-8 and Texas Government Code §531.073 and §533.005. The MCO must adhere to HHSC’s PDL for Medicaid. Preferred drugs must adjudicate as payable without prior authorization, unless they are subject to Clinical Edits. HHSC approval is required for all Clinical Edit policies and any revisions thereto. HHSC’s Medicaid and CHIP prior authorization policies, and the Medicaid PDL, are available on HHSC’s website at xxxx://xxx.xxxxxxxxxxxx.xxx/xxxxx.xxxxx. HHSC will provide the MCO written notice of changes to website information, and will identify Clinical Edits that are mandatory for MCOs on its Vendor Drug Program website. HHSC’s website includes exception criteria for each drug class included on HHSC’s Medicaid PDL. These exception criteria describe the circumstances under which a non-preferred drug may be dispensed without a prior authorization. The MCO may require that the prescriber’s office request prior authorization as a condition of coverage or payment for a prescription drug provided that: 1) a decision whether to approve or deny the prescription is made within 24 hours of the prior authorization request, and 2) if a Member’s prescription for a medication is not filled when a prescription is presented to the pharmacist due to a prior authorization requirement, the MCO must instruct the pharmacist to dispense a 72 hour emergency supply of the prescribed medication if the provider cannot be reached. The pharmacy may fill consecutive 72 hour supplies if the prescriber remains unavailable. The MCO must reimburse the pharmacy for dispensing the temporary supply of medication. The MCO may not charge pharmacies for prior authorization transaction costs or for any software costs related to processing prior authorizations. The MCO must provide access to a toll-free call center for prescribers to call to request a prior authorization for non-preferred drugs or drug that are subject to Clinical Edits. The MCO must allow prescribers to submit automated prior authorization requests, as well as requests by phone or fax. If the MCO or its PBM operates a separate call center for prior authorization requests, the prior authorization call center must meet the provider hotline performance standards set forth in Section 8.1.4.7, “Provider Hotline.” The MCO may not require a prior authorization for any drug exempted from prior authorization requi...
Prior Authorization for Prescription Drugs. Requests for covered outpatient prescription drugs may be subject to certain utilization management protocols, such as prior authorization or step therapy.
Prior Authorization for Prescription Drugs. Requests for covered outpatient prescription drugs, or certain drugs, supplies, and supplements administered by medical personnel in an office Visit, may require prior authorization or step therapy. A list of drugs subject to utilization management is available to you upon request. You may contact Member Services Monday through Friday between 7:30 a.m. and 9 p.m. Eastern Standard Time (EST) at 0-000-000-0000 or 711 (TTY). Step-therapy is a process that requires a prescription drug or sequence of prescription drugs to be used by a Member before the Health Plan will cover a prescription drug prescribed by a prescriber. We will not require step-therapy if:
