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A BILL TO BE ENTITLED
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AN ACT
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relating to certain prescription drug benefits under the Medicaid |
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managed care program. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Chapter 533, Government Code, is amended by |
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adding Subchapter C to read as follows: |
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SUBCHAPTER C. PRESCRIPTION DRUG BENEFITS UNDER CERTAIN OUTPATIENT |
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PHARMACY BENEFIT PLANS |
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Sec. 533.071. APPLICABILITY OF SUBCHAPTER. This subchapter |
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applies only to an outpatient pharmacy benefit plan implemented by |
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a Medicaid managed care organization. |
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Sec. 533.072. PREFERRED DRUG LIST EXCEPTIONS. |
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Notwithstanding any other law, a Medicaid managed care organization |
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is not required to adhere to the preferred drug list adopted by the |
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commission under Section 531.072 and shall grant an exception to |
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the list with respect to a recipient if: |
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(1) the preferred drug: |
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(A) is contraindicated; |
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(B) will likely cause an adverse reaction in or |
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physical or mental harm to the recipient; or |
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(C) is expected to be ineffective based on the |
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known clinical characteristics of the recipient and the known |
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characteristics of the prescription drug regimen; |
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(2) the recipient previously discontinued taking the |
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preferred drug at any point in the recipient's clinical history and |
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for any length of time because the drug: |
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(A) was not effective; |
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(B) had a diminished effect; or |
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(C) resulted in an adverse event; |
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(3) the preferred drug is not in the best interest of |
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the recipient, based on clinical appropriateness, because the |
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recipient's use of the drug is expected to cause a significant |
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barrier to the recipient's adherence to or compliance with the |
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recipient's plan of care; |
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(4) the recipient was prescribed and is taking a |
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nonpreferred drug in the antidepressant or antipsychotic drug class |
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and the recipient: |
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(A) was prescribed the nonpreferred drug before |
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being discharged from an inpatient facility; |
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(B) is stable on the nonpreferred drug; and |
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(C) is at risk of experiencing complications from |
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switching from the nonpreferred drug to another drug; |
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(5) the preferred drug is not available for reasons |
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outside of the Medicaid managed care organization's control, |
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including because: |
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(A) the drug is in short supply according to the |
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Food and Drug Administration Drug Shortages Database; or |
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(B) the drug's manufacturer has placed the drug |
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on backorder or allocation; or |
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(6) the preferred drug is not available at a pharmacy |
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located within a 10-mile radius of the recipient. |
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Sec. 533.073. PREFERRED DRUG LIST; SEARCHABLE DATABASE OF |
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PREFERRED DRUGS AND RESTRICTIONS. The commission shall ensure |
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that: |
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(1) an Internet-based, searchable database is made |
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available through which a provider may search the applicable |
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preferred drug list adopted by the commission under Section 531.072 |
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to easily determine whether a prescription drug or drug class is |
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subject to any prior authorization requirements, clinical edits, or |
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other clinical restrictions; and |
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(2) reasonable efforts are made to ensure the database |
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contains current information. |
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SECTION 2. If before implementing any provision of this Act |
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a state agency determines that a waiver or authorization from a |
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federal agency is necessary for implementation of that provision, |
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the agency affected by the provision shall request the waiver or |
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authorization and may delay implementing that provision until the |
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waiver or authorization is granted. |
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SECTION 3. This Act takes effect September 1, 2023. |