Section 134.501 - Initial Pharmaceutical Coverage(a) For injuries that occur on or after December 1, 2002, the insurance carrier must pay for specified pharmaceutical services sufficient for the first seven days following the date of injury, regardless of issues of liability for or compensability of the injury that the insurance carrier may have, if, before providing the pharmaceutical services, the health care provider obtains both a verification of insurance coverage and an oral or written confirmation that an injury has been reported. (1) For purposes of this rule, specified pharmaceutical services are prescription drugs and over-the-counter medications prescribed by a doctor that cure or relieve the effects naturally resulting from the compensable injury, promote recovery, or enhance the ability of the injured employee to return to or retain employment.(2) In determining the first seven days following the injury, the date of the injury is not counted. The first day after the date of injury is "day one." The last day of the seven-day period is "day seven."(3) If the pharmaceutical services are provided after day one, the insurance carrier's reimbursement under this section is limited to the date the pharmaceutical services were actually provided through day seven. (Example: The pharmaceutical services were provided on day four. The insurance carrier's liability for payment under this section would be for pharmaceutical services in an amount prescribed that would be the quantity sufficient for days four, five, six, and seven.)(4) Payment for the specified pharmaceutical services for the first seven days following the date of injury must comply with § 134.503 of this title (Pharmacy Fee Guideline). The insurance carrier must not deny, prorate, or reduce the dispensing fee for the initial prescription even if the health care provider provided pharmaceutical services beyond the first seven days following the date of injury, and the insurance carrier disputes or denies the pharmaceutical services beyond the first seven days following the date of injury.(b) The insurance carrier may be eligible for reimbursement from the subsequent injury fund (SIF) for payments made under subsection (a) as provided in Chapter 116 of this title.(c) The health care provider can verify insurance coverage and confirm the existence of a report of an injury by calling the employer or the insurance carrier. On request, the employer or the insurance carrier must verify coverage and confirm any report of an injury. For verifying insurance coverage, the health care provider can also review the division's internet-based coverage verification system. (1) The health care provider must document verifications and confirmations not obtained in writing by indicating how the verification or confirmation was obtained (date obtained, from whom, etc.).(2) The health care provider must affirm on the bill for the pharmaceutical services, in the form and manner prescribed by the division, that the health care provider verified that there is insurance coverage and confirmed that an injury has been reported.(d) Notwithstanding any other provision of this section, the health care provider may dispense prescription or nonprescription medications in the amount ordered by the prescribing doctor under applicable state and federal law (not to exceed the limits imposed by § 134.502 of this title (Pharmaceutical Services)).(e) The health care provider and insurance carrier may voluntarily discuss approval of pharmaceutical services beyond the seven days following the date of injury as provided in Texas Labor Code § 413.014(e) and § 134.600 of this title (Preauthorization, Concurrent Utilization Review, and Voluntary Certification of Health Care).(f) Communication is important to ensure prompt delivery of pharmaceutical services. (1) Injured employees are encouraged to immediately report their injury to their employer.(2) Injured employees are encouraged to ask for, and employers to provide, a written statement that confirms an injury was reported to the employer and identifies the date of injury (as reported by the injured employee) and the employer's insurance carrier. Verifying that there is insurance coverage or confirming that an injury was reported does not waive the employer's right to contest compensability under Texas Labor Code § 409.011 should the insurance carrier accept liability for the payment of benefits.(3) The insurance carrier's verification of coverage or confirmation of a reported injury does not waive the insurance carrier's right to further review the claim under Texas Labor Code § 409.021 and § 124.3 of this title (Investigation of an Injury and Notice of Denial or Dispute).28 Tex. Admin. Code § 134.501
The provisions of this §134.501 adopted to be effective November 7, 2002, 27 TexReg 10391; Amended by Texas Register, Volume 49, Number 48, November 29, 2024, TexReg 9760, eff. 11/28/2024