Texas § GV.540.0273 - OUTPATIENT PHARMACY BENEFIT PLAN

§ GV.540.0273. OUTPATIENT PHARMACY BENEFIT PLAN

OUTPATIENT PHARMACY BENEFIT PLAN. (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 Section 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 Section 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 Section 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 Section 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, 2033. Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611 ), Sec. 1.01, eff. April 1, 2025. Amended by: Acts 2025, 89th Leg., R.S., Ch. 204 (H.B. 1620 ), Sec. 8.031(a), eff. September 1, 2025.