(a) Requests for prior authorization. Except as provided in subsection (b) of this section, a health care practitioner who prescribes a drug that is not included on the Preferred Drug List (PDL) for a Medicaid recipient must request prior authorization of the drug to HHSC. Specific procedures for the submission of requests for prior authorization are available on HHSC's web site. A health care practitioner may request a printed copy of the procedures and forms from HHSC.(b) New Medicaid recipients. The PDL-related prior authorization requirement of this section does not apply if the prescription for the non-preferred drug is for a newly enrolled Medicaid recipient, until the 31st calendar day after the date of the recipient's Medicaid eligibility determination.(c) Special Considerations. When HHSC determines based on clinical considerations, cost considerations, or guidance from the Drug Utilization Review Board that the prior authorization requirement could adversely impact Medicaid recipients' health or safety, it may be administratively more efficient to deem the approved prior authorization for a particular client for a certain period of time, or for an indefinite period.(d) Disposition of requests for prior authorization. HHSC or its designee will notify the requesting practitioner of the approval or disapproval of the request within 24 hours of the receipt of the request.(e) Emergency requests for prior authorization. HHSC will authorize up to a 72-hour supply of a product subject to prior authorization if:(1) the prescribing practitioner notifies HHSC of an emergency need for the product when submitting the request for prior authorization; and(2) HHSC or its designee is unable to provide its approval or disapproval within 24 hours following the receipt of the request.(f) The PDL prior authorization exception criteria are as follows:(1) treatment failure with preferred drug;(2) contraindication to preferred drug; and(3) allergic reaction to preferred drugs.(g) Additional PDL prior authorization exception criteria that HHSC considers includes Texas Insurance Code §1369.213, concerning prior authorization exceptions for coverage of stage-four advanced, metastatic cancer.(h) The following PDL prior authorization exception criteria are added by Texas Government Code §533.071:(1) the drug required under the preferred drug list:(A) is contraindicated;(B) will likely cause an adverse reaction in or physical or mental harm to the recipient; or(C) is expected to be ineffective based on the known clinical characteristics of the recipient and the known characteristics of the prescription drug regimen;(2) the recipient previously discontinued taking the preferred drug at any point in the recipient's clinical history and for any length of time because the drug:(A) was not effective;(B) had a diminished effect; or(C) resulted in an adverse event;(3) the recipient was prescribed and is taking a nonpreferred drug in the antidepressant or antipsychotic drug class and the recipient:(A) was prescribed the nonpreferred drug before being discharged from an inpatient facility;(B) is stable on the nonpreferred drug; and(C) is at risk of experiencing complications from switching from the nonpreferred drug to another drug; or(4) the preferred drug is not available for reasons outside of the Medicaid managed care organization's control, including because:(A) the drug is in short supply according to the Food and Drug Administration Drug Shortages Database; or(B) the drug's manufacturer has placed the drug on backorder or allocation.