Section 540.0273 - [Effective 4/1/2025] 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, 2023. (Gov. Code, Secs. 533.005(a)(23)(A), (B), (C), (C-1), (C-2), (a-1).)Tex. Gov't. Code § 540.0273
Added by Acts 2023, Texas Acts of the 88th Leg.- Regular Session, ch. 769,Sec. 1.01, eff. 4/1/2025.