Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter S - FORMS TO REQUEST PRIOR AUTHORIZATION › Division 3 - TEXAS STANDARD PRIOR AUTHORIZATION REQUEST FORM FOR PRESCRIPTION DRUG BENEFITS › Section 19.1820 - Prior Authorization Request Form for Prescription Drug Benefits, Required Acceptance, and Use

Current through Reg. 49, No. 28; July 12, 2024
(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.