Texas Secretary of State

Texas Health and Human Services Commission

Texas Department Of Insurance TAC

Chapter 19: Licensing And Regulation Of Insurance Professionals

Subchapter S: Forms To Request Prior Authorization

Division 3: Texas Standard Prior Authorization Request Form For Prescription Drug Benefits

Section 19.1820: Prior Authorization Request Form For Prescription Drug Benefits, Required Acceptance, And Use

Texas Health And Human Services Commission TAC

Chapter 351: Children with Special Health Care Needs Services Program

Chapter 353: Medicaid Managed Care

Subchapter J: Outpatient Pharmacy Services

Section 353.901: Purpose
Section 353.903: Definitions
Section 353.905: Managed Care Organization Requirements
Section 353.907: Prior Authorization Requirements
Section 353.909: Participating Pharmacy Providers
Section 353.911: Members
Section 353.913: Managed Care Organization Requirements Concerning Out-of-Network Outpatient Pharmacy Services
Section 353.915: Access to Network Pharmacies

Chapter 354: Medicaid Health Services

Subchapter A: Purchased Health Services

Division 3: Medicaid Home Health Services

Section 354.1031: General
Section 354.1035: Recipient Qualifications for Home Health Services
Section 354.1037: Written Plan of Care
Section 354.1039: Benefits and Limitations of Home Health Services
Section 354.1040: Requirements for Wheeled Mobility Systems
Section 354.1042: Supplies Provided by a Pharmacy
Section 354.1043: Competitive Procurement of Durable Medical Equipment (DME) and Supplies

Subchapter F: Pharmacy Services

Division 1: Participation

Section 354.1801: Requirements for Participation
Section 354.1803: Confidentiality
Section 354.1805: Nondiscrimination
Section 354.1807: Access to Records
Section 354.1809: Denial or Termination of Participation
Section 354.1811: Sanctions
Section 354.1813: Placing a Pharmacy Provider on Vendor Hold

Division 2: Administration

Section 354.1831: Covered Drugs
Section 354.1832: Prior Authorization Procedures
Section 354.1833: Pharmacy Services
Section 354.1835: Prescriber Identification Numbers
Section 354.1837: Evidence of Eligibility

Division 3: Medications

Section 354.1851: Substitution of One Drug for Another in a Prescription
Section 354.1853: Specialty Drugs

Division 4: Limitations

Section 354.1861: Availability of Funds
Section 354.1863: Prescription Requirements
Section 354.1867: Refills
Section 354.1868: Exceptions in Disasters
Section 354.1871: Advertising
Section 354.1875: Limitations on Provider Charges to Recipients
Section 354.1877: Quantity Limitations

Division 5: Audits

Section 354.1891: Vendor Drug Providers Subject to Audit
Section 354.1892: Exception Notification

Division 6: Pharmacy Claims

Section 354.1901: Pharmacy Claims
Section 354.1905: Claim Adjustments
Section 354.1907: Unacknowledged Claims
Section 354.1909: Submittal of Special Claims
Section 354.1911: Electronic Data Transmission Vendors (Switches)

Division 7: Texas Drug Code Index--Additions, Retentions, And Deletions

Section 354.1921: Addition of Drugs to the Texas Drug Code Index
Section 354.1923: Review and Evaluation
Section 354.1924: Preferred Drug List
Section 354.1925: Resubmittal of a Denied Request
Section 354.1927: Retention and Deletion of Drugs

Division 8: Drug Utilization Review Board

Section 354.1941: Drug Utilization Review Board
Section 354.1942: Conflict of Interest Policy

Chapter 355: Reimbursement Rates

Subchapter J: Purchased Health Services

Division 5: General Administration

Section 355.8085: Reimbursement Methodology For Physicians And Other Practitioners

Division 28: Pharmacy Services: Reimbursement

Section 355.8541: Legend and Nonlegend Medications
Section 355.8542: Drug Price Effective Date
Section 355.8543: Nonlegend Drug Restrictions
Section 355.8544: Usual and Customary Prices
Section 355.8546: Brand-Name Drugs
Section 355.8547: Reimbursement for Compound Prescriptions
Section 355.8548: 340B Covered Entities
Section 355.8549: Reimbursement to Hospitals and Physicians Who Dispense Drugs
Section 355.8550: Third-Party Resources
Section 355.8551: Professional Dispensing Fee

Chapter 365: Kidney Health Care

Chapter 382: Women's Health Services

Subchapter A: Healthy Texas Women

Texas State Board Of Pharmacy TAC

Chapter 291: Pharmacies

Subchapter B: Community Pharmacy (Class A)

Section 291.33: Operational Standards
Section 291.34: Records

Chapter 295: Pharmacists

Section 295.15: Administration of Immunizations or Vaccinations by a Pharmacist under Written Protocol of Physician

Texas Government Code

Introduction

Texas Legislature

Texas Constitution and Statutes

Title 4 – Executive Branch, Subtitle I – Health and Human Services

Chapter 531: Health and Human Services Commission

Subchapter A - General Provisions; Organization of Commission

Section 531.069: Periodic Review of Vendor Drug Program
Section 531.0693: Prescription Drug Use and Expenditure Patterns
Section 531.0694: Period of Validity for Prescription
Section 531.0696: Considerations in Awarding Certain Contracts
Section 531.0697: Prior Approval and Provider Access to Certain Communications with Certain Recipients
Section 531.070: - Supplemental Rebates
Section 531.071: Confidentiality of Information Regarding Drug Rebates, Pricing, And Negotiations
Section 531.072: Preferred Drug Lists
Section 531.073: Prior Authorization for Certain Prescription Drugs
Section. 531.0735: Medicaid Drug Utilization Review Program: Drug Use Reviews and Annual Reports
Section 531.736: Drug Utilization Review Board
Section 531.0737: Drug Utilization Review Board: Conflicts Of Interest
Section 531.0741: Publication of Information Regarding Commission Decisions On Preferred Drug List Placement
Section 531.089: Certain Medications for Sex Offenders Prohibited

Chapter 533: Implementation of Medicaid Managed Care Program

Subchapter A - General Provisions

Section 533.033(b): Considerations in awarding contracts (Awarding Pharmacy Benefit Management Subcontracts)
Section 533.005: Required Contract Provisions (A)(23)
Section 533.0161: Monitoring of Psychotropic Drug Prescriptions for Certain Children

Texas Human Resources Code

Title 2. Human Services And Protective Services In General

C. Assistance Programs

Chapter 32. Medical Assistance Program

Subchapter B. Administrative Provisions

Section 32.024: Authority and Scope of Program; Eligibility (z,bb,ii)
Section 32.046: Sanctions and Penalties related to the Provision of Pharmacy Products. (a, b)
Section 32.0461: Vendor Drug Program; Competitive Bidding (A)
Section 32.0462: Vendor Drug Program; Pricing Standard (1,2,b)

Chapter 36. Medicaid Fraud Prevention

Subchapter B. Action By Attorney General

Section 36.052: Civil Remedies

Texas Insurance Code

Title 6. Organization of Insurers and Related Entities

Subtitle C. Life, Health, and Accident Insurers and Related Entities

Chapter 843. Health Maintenance Organizations

Subchapter F. Relations with Enrollees and Group Contract Holders

Section 843.2015: Information Available Through Internet Site

Subchapter J. Payment of Claims to Physicians and Providers

Section 843.339: Deadline for Action on Prescription Claims Payment.

Title 8. Health Insurance and Other Health Coverages

Subtitle A. Health Coverage in General

Chapter 1217. Standard Request Form for Prior Authorization of Health Services

Section 1217.004: Standard Form

Subtitle E. Benefits Payable Under Health Coverages

Chapter 1369. Benefits Related to Prescription Drugs and Devices and Related Services

Subchapter G. Standard Request Form for Prior Authorization of Prescription Drug Benefit

Section 1369.304: Standard Form

Subchapter J. Coverage Related to Prescription Drug Synchronization

Section 1369.451: Definitions
Section 1369.452: Applicability Of Subchapter
Section 1369.453: Applicability To Certain Medications
Section 1369.454: Proration Of Cost-Sharing Amount Required
Section 1369.455: Proration Of Dispensing Fee Prohibited
Section 1369.456: Implementation Of Certain Medication Synchronization Plans

Title 14. Utilization Review and Independent Review

Chapter 4201. Utilization Review Agents

Texas Occupations Code

Title 3. Health Professions

Subtitle J. Pharmacy And Pharmacists

Chapter 554. Board Powers And Duties; Rulemaking Authority

Subchapter A. Powers And Duties

Section 554.004: Administration Of Medication

Texas Penal Code

Title 8. Offenses Against Public Administration

Chapter 37. Perjury And Other Falsification

Sec. 37.10: Tampering With Governmental Record

U.S. Code of Federal Regulations

Introduction

U.S. Code of Federal Regulations

Code of Federal Regulations

Title 42 - Chapter IV - Subchapter C

Part 438 - Managed Care

Subpart A (General Provisions)

42 CFR Section 438.3(s): Requirements for MCOs, PIHPs, or PAHPs that provide covered outpatient drugs

Part 440 - Services: General Provisions

Subpart A (Definitions)

42 CFR Section 440.70: Home Health Services
42 CFR Section 440.120: Prescribed drugs, dentures, prosthetic devices, and eyeglasses

Part 447 - Payments for Services

Subpart I (Payment for Drugs)

42 CFR Section 447.500: Basis and Purpose
42 CFR Section 447.502: Definitions
42 CFR Section 447.504: Determination of average manufacturer price
42 CFR Section 447.505: Determination of Best Price
42 CFR Section 447.506: Authorized Generic Drugs
42 CFR Section 447.508: Exclusion from Best Price Of Certain Sales At A Nominal Price
42 CFR Section 447.510: Requirements for Manufacturers
42 CFR Section 447.512: Drugs: Aggregate Upper Limits of Payment
42 CFR Section 447.516: Upper Limits For Drugs Furnished As Part of Services
42 CFR Section 447.518: State Plan Requirements, Findings and Assurances
42 CFR Section 447.520: FFP: Conditions Relating To Physician-Administered Drugs

Part 456 - Utilization Control

Subpart K (Drug Use Review Program and Electronic Claims Management System for Outpatient Drug Claims)

42 CFR Section 456.700: Scope
42 CFR Section 456.702: Definitions
42 CFR Section 456.703: Drug Use Review Program
42 CFR Section 456.705: Prospective Drug Review
42 CFR Section 456.709: Retrospective Drug Use Review
42 CFR Section 456.711: Educational Program
42 CFR Section 456.712: Annual Report
42 CFR Section 456.714: DUR/Surveillance And Utilization Review Relationship
42 CFR Section 456.716: DUR Board
42 CFR Section 456.719: Funding For Dur Program
42 CFR Section 456.722: Electronic Claims Management System
42 CFR Section 456.725: Funding Of ECM System

U.S. Social Security Act

Title XIX—Grants to States For Medical Assistance Programs

Section 1905: Definitions
Section 1927: Payment For Covered Outpatient Drugs