TX State Updates - 2015 Jan 21 No.02

pOn June 14, 2013, during its regular 83rd Legislative session, the Texas legislature passed SB 644, requiring the Texas Department of Insurance (TDI) to adopt a rule creating a standard form that prescribing providers can use to request prior authorization of prescription drug benefits from health benefit plan issuers. (Note that the Texas legislature is currently in its 84th legislative session.) On April 7, 2015, TDI published a new rule in response to SB 644, which requires certain issuers of health care services and their agents to accept and use a standard form for all authorizations of prescription drug benefits for which the issuer’s plan requires prior authorization. The rule also requires TDI, the issuer, and the issuer’s agent to make the form available electronically on their websites.

Importantly, the form is not used to 1) request an appeal, 2) confirm eligibility, 3) verify coverage, 4) request a guarantee of payment, 5) ask whether a prescription drug or device requires prior authorization or 6) request prior authorization of a health care service. While directed at issuers, it is helpful for employers in Texas to be familiar with this new standardized form if they cover prescription drugs requiring prior authorization, especially since such a broad range of issuers must accept the form, including: commercial issuers, Medicaid, the Medicaid managed care program, the Children’s Health Insurance Program (CHIP) and plans covering employees of the state of Texas, most school districts and The University of Texas and Texas A&M Systems. Employers that have purchased group health plans which require prior authorization for prescription drug benefits should direct participants to the issuer website to complete this prior authorization form on an as needed basis. The rule is effective Sept. 1, 2015.

Standard Prior Authorization Request Form »
Instructions »
Final Rule »
SB 644 »