SECTION 19.1820. Prior Authorization Request Form for Prescription Drug Benefits, Required Acceptance, and Use

(a) Form requirements. The commissioner adopts by reference the Prior Authorization Request Form for Prescription Drug Benefits form, to be accepted and used by an issuer in compliance with subsection (b) of this section. The form and its instruction sheet are on TDI's website at www.tdi.texas.gov/forms/form10.html; or the form and its instruction sheet can be requested by mail from the Texas Department of Insurance, Rate and Form Review Office, MC: LH-MCQA, PO Box 12030, Austin, Texas 78711-2030. The form must be reproduced without changes. The form provides space for the following information:

(1) the name of the issuer or the issuer's agent that manages prescription drug benefits, telephone number, and fax number;

(2) the date the request is submitted;

(3) a place to request an expedited or urgent review if the prescribing provider or the prescribing provider's designee certifies that applying the standard review time frame may seriously jeopardize the life or health of the patient or the patient's ability to regain maximum function;

(4) the patient's name, contact telephone number, date of birth, sex, address, and identifying insurance information;

(5) the prescribing provider's name, NPI number, specialty, telephone and fax numbers, address, and contact person's name and telephone number;

(6) for a prescription drug:

(A) drug name;

(B) strength;

(C) route of administration;

(D) quantity;

(E) number of days' supply;

(F) expected therapy duration; and

(G) to the best of the prescribing provider's knowledge, whether the medication is:

(i) a new therapy; or

(ii) continuation of therapy, and if so, to the best of the prescribing provider's knowledge:

(I) the approximate date therapy was initiated;

(II) whether the patient is adhering to the drug therapy regimen; and

(III) whether the drug therapy regimen is effective;

(7) for a provider administered drug, the HCPCS code, NDC number, and dose per administration;

(8) for a prescription compound drug, its name, ingredients, and each ingredient's NDC number and quantity;

(9) for a prescription device, its name, expected duration of use, and, if applicable, its HCPCS code;

(10) the patient's clinical information, including:

(A) diagnosis, ICD version number (if more than one version is allowed by the U.S. Department of Health and Human Services), and ICD code;

(B) to the best of the prescribing provider's knowledge, the drugs the patient has taken for this diagnosis, including:

(i) drug name, strength, and frequency;

(ii) the approximate dates or duration the drugs were taken; and

(iii) patient's response, reason for failure, or allergic reaction;

(C) the patient's drug allergies, if any; and

(D) the patient's height and weight, if relevant;

(11) a list of relevant lab tests, and their dates and values;

(12) a place for the prescribing provider to:

(A) include pertinent clinical information to justify requests for initial or ongoing therapy, or increases in current dosage, strength, or frequency;

(B) explain any comorbid conditions and contraindications for formulary drugs; or

(C) provide details regarding titration regimen or oncology staging, if applicable; and

(13) a directive to the prescribing provider stating that:

(A) for a request for prior authorization of continuation of therapy (other than a request for a step-therapy exception as provided in subparagraph (B) of this paragraph), it is not necessary to complete the sections of the form regarding patient clinical information and justification for the therapy unless there has been a material change in the information previously provided; and

(B) for a request for a step-therapy exception, the section of the form regarding justification for the step-therapy exception must be completed.

(b) Acceptance and use of the form.

(1) If a prescribing provider submits the form to request prior authorization of a prescription drug benefit for which the issuer's plan requires prior authorization, the issuer must accept and use the form for that purpose. An issuer may also have on its website another electronic process a prescribing provider may use to request prior authorization of a prescription drug benefit.

(2) This form may be used by a prescribing provider to request prior authorization of:

(A) a prescription drug;

(B) a prescription device;

(C) formulary exceptions;

(D) quantity limit overrides; and

(E) step-therapy requirement exceptions.

(3) This form may not be used by a prescribing provider to:

(A) request an appeal;

(B) confirm eligibility;

(C) verify coverage;

(D) ask whether a prescription drug or device requires prior authorization; or

(E) request prior authorization of a health care service.

(c) Effective date. An issuer must accept a request for prior authorization of prescription drug benefits made by a prescribing provider using the form on or after the effective date of this section. An issuer must accept a request using the form that was in place prior to the effective date of this section for 90 days after the effective date.

(d) Availability of the form.

(1) A health benefit plan issuer must make the form available electronically on its website.

(2) A health benefit plan issuer's agent that manages or administers prescription drug benefits must make the form available electronically on its website.

Source Note: The provisions of this §19.1820 adopted to be effective September 1, 2015, 40 TexReg 2193; amended to be effective August 11, 2022, 47 TexReg 4681; amended to be effective June 19, 2023, 48 TexReg 3285