88R9379 JG-F
By: Klick H.B. No. 3286
A BILL TO BE ENTITLED
AN ACT
relating to certain prescription drug benefits under the Medicaid
managed care program.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 533, Government Code, is amended by
adding Subchapter C to read as follows:
SUBCHAPTER C. PRESCRIPTION DRUG BENEFITS UNDER CERTAIN OUTPATIENT
PHARMACY BENEFIT PLANS
Sec. 533.071. DEFINITION. In this subchapter, "step
therapy protocol" means a protocol that requires a recipient to use
a prescription drug or sequence of prescription drugs other than
the drug that the recipient's physician recommends for the
recipient's treatment before a Medicaid managed care organization
provides coverage for the recommended drug.
Sec. 533.072. APPLICABILITY OF SUBCHAPTER. This subchapter
applies only to an outpatient pharmacy benefit plan implemented by
a Medicaid managed care organization.
Sec. 533.073. STEP THERAPY PROTOCOL EXCEPTION REQUESTS.
(a) A Medicaid managed care organization shall establish a process
in a user-friendly format through which a step therapy protocol
exception request may be submitted by a prescribing provider. The
process must be readily accessible to:
(1) a recipient who enrolls in a managed care plan
offered by the organization or transfers to a managed care plan
offered by the organization from a managed care plan offered by
another Medicaid managed care organization; and
(2) the provider.
(b) A prescribing provider on behalf of a recipient may
submit in written or electronic form or by telephone to the
recipient's Medicaid managed care organization an exception
request for a step therapy protocol required by the recipient's
Medicaid managed care organization.
(c) A Medicaid managed care organization shall review and,
if clinically appropriate, grant an exception request under
Subsection (b) if the request includes a statement by the
prescribing provider stating that:
(1) the drug required under the step therapy protocol:
(A) is contraindicated;
(B) will likely cause an adverse reaction in or
physical or mental harm to the recipient; or
(C) is expected to be ineffective based on the
known clinical characteristics of the recipient and the known
characteristics of the prescription drug regimen;
(2) the recipient previously discontinued taking the
drug required under the step therapy protocol:
(A) while enrolled in a managed care plan offered
by the recipient's current Medicaid managed care organization or
while enrolled in a managed care plan offered by another Medicaid
managed care organization; and
(B) because the drug was not effective or had a
diminished effect or because of an adverse event;
(3) the drug required under the step therapy protocol
is not in the best interest of the recipient, based on clinical
appropriateness, because the recipient's use of the drug is
expected to:
(A) cause a significant barrier to the
recipient's adherence to or compliance with the recipient's plan of
care;
(B) worsen a comorbid condition of the recipient;
or
(C) decrease the recipient's ability to achieve
or maintain reasonable functional ability in performing daily
activities; or
(4) the drug that is subject to the step therapy
protocol was prescribed for the recipient's condition while
enrolled in a managed care plan offered by the recipient's current
Medicaid managed care organization or while enrolled in a managed
care plan offered by a previous Medicaid managed care organization
and the recipient is stable on the drug.
(d) Except as provided by Subsection (e), if a Medicaid
managed care organization does not deny an exception request under
Subsection (b) before 72 hours after the organization receives the
request, the request is considered granted.
(e) If a statement described by Subsection (c) also states
that the prescribing provider reasonably believes that denial of
the exception request makes the death of or serious harm to the
recipient probable, the request is considered granted if the
Medicaid managed care organization does not deny the request before
24 hours after the organization receives the request.
(f) A Medicaid managed care organization may not require a
prescribing provider to submit a subsequent exception request under
Subsection (b) for a drug for treatment of a recipient's condition
for which the organization has already granted an exception to a
step therapy protocol for the recipient unless the organization's
medical director determines that the drug for treatment under the
previously granted exception request will likely cause physical or
mental harm to the recipient.
Sec. 533.074. PREFERRED DRUG LIST; SEARCHABLE DATABASE OF
PREFERRED DRUGS AND RESTRICTIONS. (a) A Medicaid managed care
organization shall distribute current copies of the organization's
preferred drug list by posting the list on the organization's
Internet website.
(b) A Medicaid managed care organization shall maintain on
the organization's Internet website a searchable database through
which a provider may search the organization's preferred drug list
to easily determine whether a prescription drug or drug class is
subject to any prior authorization requirements, clinical edits, or
other clinical restrictions. An organization shall make reasonable
efforts to ensure that the database contains current information.
SECTION 2. If before implementing any provision of this Act
a state agency determines that a waiver or authorization from a
federal agency is necessary for implementation of that provision,
the agency affected by the provision shall request the waiver or
authorization and may delay implementing that provision until the
waiver or authorization is granted.
SECTION 3. This Act takes effect September 1, 2023.