Deadline for Draft Policy Review Due Feb. 7, 2024

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The HHSC Vendor Drug Program (VDP) accepts stakeholder comments on the following draft policy. The comment period ends Feb. 7, 2024. Submit your comments using the Draft Policy Comment Submission (HHS Form 1342). VDP will consider the comments in the development of the final policy, and will share the final policy and implementation date for Medicaid in the future. 

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HB 3286, 88th Legislature, amends Section 531.072 of the Texas Government Code to grant temporary non-preferred status to new drugs that are available on the Medicaid formulary but have not been reviewed by the Drug Utilization Review Board (DURB) and establish criteria for coverage.

This change requires the Centers for Medicare and Medicaid Services (CMS) approval of a Medicaid State Plan Amendment (SPA). The Texas Health and Human Services Commission (HHSC) is soliciting public comment on the temporary non-preferred drug policy. The policy will be submitted as part of the SPA request to CMS.

Draft Policy

  1. HHSC will identify available new-to-market preferred drug list (PDL) drugs through the Drug Addition Process and assign a temporary non-preferred status to available new-to-market PDL drugs that have not been reviewed by the DURB. The temporary non-preferred status will apply to available new-to-market PDL drugs immediately if added to the Texas Medicaid formulary and will remain until reviewed at a future DURB meeting. Drugs on the Texas Medicaid formulary with a temporary non-preferred status will require a PDL prior authorization for coverage.
  2. Prescribers may obtain coverage of a temporary non-preferred drug by requesting a PDL prior authorization for members who meet the exception criteria listed below:
    1. Temporary non-preferred drug is necessary for the treatment of stage 4 advanced metastatic cancer and associated conditions.
    2. Appropriate diagnosis for the FDA-approved indication of the requested temporary non-preferred drug.
    3. Appropriate drug dosage for the member’s age and indication.
    4. Member must not have any contraindications or drug allergies that would prevent treatment of the requested temporary non-preferred drug.
  3. Approved PDL prior authorization duration for temporary non-preferred drugs will be granted for 180 days. 

Medicaid managed care organizations will be required to adhere to this policy and criteria when reviewing PDL prior authorizations.