Section 353.903 - DefinitionsThe following words and terms, when used in this subchapter, have the following meaning unless the context clearly indicates otherwise.
(1) Clinical prior authorization (clinical PA)--A review process authorized by HHSC that is conducted by a healthcare managed care organization (health care MCO) prior to dispensing a drug. All clinical PAs must be identified on the Medicaid Vendor Drug Program website at http://www.txvendordrug.com.(2) Covered outpatient drug--A drug or biological product included on the formulary and provided in an outpatient setting.(3) Formulary--The list of covered outpatient drugs for the Texas Medicaid program.(4) Maximum allowable cost--The highest unit price set by a health care MCO, or its subcontractor, for reimbursement of therapeutically equivalent multi-source drugs.(5) Network provider--A pharmacy provider who has entered into a contract with the health care MCO to provide outpatient drug benefits to Medicaid enrollees.(6) Non-preferred drug--A covered outpatient drug on the preferred drug list (PDL) that has been designated as non-preferred.(7) Pharmacy benefits manager (PBM)--An entity that administers the Medicaid outpatient drug benefit on behalf of a health care MCO.(8) Preferred drug--A covered outpatient drug on the PDL that has been designated as preferred because it has been evaluated to be safe, clinically effective, and cost-effective compared to other drugs in the same therapeutic drug class on the market.(9) Preferred drug list (PDL)--The list of covered outpatient drugs reviewed by the Drug Utilization Review Board (DUR Board) . Reviewed drugs are recommended by the DUR Board as either preferred or non-preferred and HHSC establishes the final designation.(10) Preferred drug list prior authorization (PDL PA)--A review conducted by a health care MCO prior to dispensing a non-preferred drug.1 Tex. Admin. Code § 353.903
The provisions of this §353.903 adopted to be effective March 1, 2012, 37 TexReg 1292; Amended to be effective September 1, 2013, 38 TexReg 5429; Amended by Texas Register, Volume 41, Number 06, February 5, 2016, TexReg 960, eff. 2/9/2016