Texas Administrative Code
Title 28 - INSURANCE
Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION
Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS
Subchapter F - PHARMACEUTICAL BENEFITS
Section 134.510 - Transition to the Use of the Closed Formulary for Claims with Dates of Injury Prior to September 1, 2011

Universal Citation: 28 TX Admin Code ยง 134.510

Current through Reg. 49, No. 38; September 20, 2024

(a) Applicability. This section applies to claims with dates of injury prior to September 1, 2011 (for the purposes of this section, referred to as "legacy claims"), which are subject to § 134.530 of this title (relating to Requirements for Use of the Closed Formulary for Claims Not Subject to Certified Networks), § 134.540 of this title (relating to Requirements for Use of the Closed Formulary for Claims Subject to Certified Networks), and § 134.550 of this title (relating to Medical Interlocutory Order) on and after September 1, 2013.

(b) Transition of legacy claims.

(1) At any time after September 1, 2011 and prior to September 1, 2013:
(A) The prescribing doctor should include a statement of medical necessity as defined in § 134.500(13) of this title (relating to Definitions) with the prescription for drugs excluded from the closed formulary.

(B) The prescribing doctor or the insurance carrier may contact each other for a discussion of ongoing pharmacological management of the injured employee's claim.

(C) When a prescribing doctor or insurance carrier is contacted by the other party regarding ongoing pharmacological management, the parties must provide each other a name, phone number, and date and time to discuss ongoing pharmacological management of the injured employee's claim.

(2) Beginning no later than March 1, 2013, the insurance carrier shall:
(A) identify all legacy claims that have been prescribed a drug excluded from the closed formulary after September 1, 2012; and

(B) provide written notification to the injured employee, prescribing doctor, and pharmacy if known, that contains the following:
(i) the notice of the impending date and applicability of the closed formulary for legacy claims; and

(ii) the information required in paragraph (1)(C) of this subsection.

(c) Agreement. To ensure continuity of care, notwithstanding subsection (a) of this section, an insurance carrier and a prescribing doctor may enter into an agreement regarding the application of the pharmacy closed formulary for individual legacy claims on claim-by-claim basis.

(d) Agreement requirements.

(1) The insurance carrier shall document any agreement and the terms, and share a copy of the agreement with the prescribing doctor and injured employee.

(2) Health care provided as a result of the agreement is not subject to retrospective review of medical necessity.

(3) Denial of a request for an agreement is not subject to dispute resolution.

(4) If no agreement is reached and documented by September 1, 2013 for a legacy claim, the requirements of §§ 134.530, 134.540, and 134.550 of this title shall apply.

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