Texas Enacts “Gold Card” Law on Prior Authorization Streamlining the Process for Receiving Approval
The State of Texas recently enacted H.R. 3459, a law that permits prescribers to earn a “gold card” exemption from Prior Authorization (PA) requirements based on a track record of previous PA approvals from insurers (preferred provider and exclusive provider benefit plans) including Medicaid managed care organizations and health maintenance organizations (HMOs). Providers with a 90% PA approval rate (based on a retrospective review of 5-20 claims over a six month period) get a one year “rolling approval” if they order the same drug or test. The law, which becomes effective in September 2021, will facilitate patient’s receiving their medication and avoid bureaucratic delays caused by the need to wait for PA approvals. The law encompasses PAs for both prescription drugs and other procedures, as well as treatments such as imaging.
The concept of Prior Authorizations has crept into all aspects of patient care, even being required for certain generic drugs. The bill was unsuccessfully opposed by the Texas Association of Health Plans and the Texas Employers for Insurance Reform, both of whom stated it would result in unnecessary and inappropriate use of medications and service, while increasing the costs of healthcare and insurance. An important feature of the new law is that for PA requests, it now requires that physicians be given an opportunity to speak to a Texas licensed physician of same or similar specialty.
In 2018, a consensus statement between the American Medical Association, American Hospital Association, America’s Health Insurance Plans, American Pharmacists Association, Blue Cross Blue Shield Association and the Medical Group Management Association concurred that reforms were needed to reduce PA burdens and enhance patient-centered care. Despite this, in most states, PA burdens continue unabated, and legislative remedies are greatly needed. PA for prescription drugs continues to be an issue for Medicare Part D.
How Frier Levitt Can Help
Frier Levitt engages various stakeholders including professional organizations to assist with grassroots efforts for PA reform on a state and federal level. Contact us to speak to our Legislative Advocacy group to learn more.
 The Gold Card can be rescinded if the approval falls blow 90%.