CurrentBaylor Scott & White Health PlanPolicy N/A

Texas Prescriber Gold-Card Prior Authorization Exemption

Defines Capital Rx's gold-card program for Texas prescribers that exempts qualifying prescribers from submitting prior authorizations for specific drugs and eligible Texas-regulated plans; affects prescribers and administration of PA processing for those plans.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyTexas Prescriber Gold-Card Prior Authorization Exemption

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionOnce granted gold-card status, the prescriber no longer needs to submit prior authorization requests for the specified drugs and eligible Texas-regulated plans.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5min PAs required to qualify

90%min PA approval rate

up to 2reviews per year

30 daysprovider response time

5 daysIRO notification

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Gold-Card Qualification and Coverage Criteria

Gold-card coverage criteria and processes

Qualification and maintenance criteria for gold-card status:

Prescriber must have submitted at least 5 prior authorization requests for a specific drug during the TDI-specified six-month review period.

Prescriber must have achieved a 90% or higher PA approval rate for that drug within the eligible plan during the review period.

Once granted, prescriber is exempt from submitting PAs for that drug under the designated eligible Texas-regulated plan; Capital Rx will cancel any submitted PAs for those drugs and allow claims to process as if a PA had been approved.

Capital Rx will monitor gold-carded prescribers up to twice yearly by sampling 5 to 20 random payable claims per exempted drug covering a six-month period determined by TDI.

Failure conditions

If review finds sampled claims would not have met PA approval standards, Capital Rx may revoke gold-card status.
If provider fails to supply requested medical records or other necessary documents within 30 days of request, Capital Rx may determine claims would not have met PA requirements and revoke status.

If gold-card status is rescinded, the provider may appeal using the form included with the rescission notice; appeals and any requested records are forwarded to TDI and an independent review organization for review.

Gold-card exemptions apply only to eligible Texas-regulated plans and specified drugs and do not apply to Medicare.

Gold-card status remains valid until the provider is notified that it has been rescinded; additional drugs may be added following future reviews.

Provider Responsibilities, Exemptions, Reviews, and Appeals

Prior Authorization

Gold-card PA exemption and communication

Once a prescriber is granted gold-card status, the prescriber no longer needs to submit prior authorization requests for the specified drugs and eligible Texas-regulated plans; Capital Rx will cancel any submitted PAs for those drugs and allow claims to process as if a PA had been approved. For questions or to update contact information, contact TXGoldCardSupport@cap-rx.com. Gold-card exemptions do not apply to Medicare.

Denial Risk

Review and potential rescission process

Capital Rx reviews gold-carded prescribers up to twice yearly by sampling 5 to 20 payable claims per exempted drug over a TDI-determined six-month period. Capital Rx may request medical records or other documents during the review; providers have 30 days to respond. If requested records are not provided or the review shows claims would not have met PA criteria, Capital Rx may revoke gold-card status and will include sampled-claim findings and reasons in the rescission notice.

Reviews include 5–20 random payable claims per exempted drug over a six-month TDI-specified period.
Providers have 30 days to supply requested medical records or documents.
Rescission notices will detail the number of payable claims, number reviewed, findings per claim, and the clinical or administrative reasons for noncompliance.

Documentation Required

Appeal and independent review procedure

If gold-card status is rescinded, the provider may appeal using the form included with the rescission notice; the appeal and any missing records must be submitted (electronically or postmarked) before the rescission effective date. Appeals and the related claims and records are sent to the Texas Department of Insurance (TDI), which forwards them to an Independent Review Organization (IRO); if requested, an additional random sample may be reviewed.

Appeal must be submitted before the rescission effective date and be electronically sent or postmarked with the submission date documented.
If rescission resulted from missing records, those records must be included with the appeal.
TDI forwards appeals and materials to an IRO; TDI will provide the IRO a list of payable claims if a new random sample is requested.

Key Terms and Eligible Plans

Gold-card status (definition)

DefinitionGold-card status is an exemption granted to Texas prescribers who submitted at least five prior authorization requests for a specific drug and achieved a 90% or higher PA approval rate during the TDI-defined six-month evaluation period, removing the need to submit PAs for those drugs under specified eligible plans.

EffectPrescriber no longer needs to submit prior authorization requests for the specified drug under the eligible plan once gold-card status is granted.

Scope of determinationGold-card status is determined at both the eligible plan and drug level (status applies per drug and per eligible plan).

Plan applicability

Eligible plansTexas state-regulated commercial plans: fully insured large and small group, and individual plans

Medicare exclusionGold-card exemptions do not apply to Medicare.

Contact for questionsTXGoldCardSupport@cap-rx.com for questions or updates to contact preferences for gold-card communications.