Sec. 1369.004. COVERAGE REQUIRED. (a) A health benefit plan that covers drugs must cover any drug prescribed to treat an enrollee for a chronic, disabling, or life-threatening illness covered under the plan if the drug:
(1) has been approved by the United States Food and Drug Administration for at least one indication; and
(2) is recognized by the following for treatment of the indication for which the drug is prescribed:
(A) a prescription drug reference compendium approved by the commissioner for purposes of this section; or
(B) substantially accepted peer-reviewed medical literature.
(b) Coverage of a drug required under Subsection (a) must include coverage of medically necessary services associated with the administration of the drug.
(c) A health benefit plan issuer may not, based on a "medical necessity" requirement, deny coverage of a drug required under Subsection (a) unless the reason for the denial is unrelated to the legal status of the drug use.
(d) This section does not require a health benefit plan to cover:
(1) experimental drugs that are not otherwise approved for an indication by the United States Food and Drug Administration;
(2) any disease or condition that is excluded from coverage under the plan; or
(3) a drug that the United States Food and Drug Administration has determined to be contraindicated for treatment of the current indication.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Section: Previous 1369.001 1369.002 1369.003 1369.004 1369.005 1369.051 1369.052 1369.053 1369.054 1369.0541 1369.0542 1369.0543 1369.0544 1369.055 1369.056 NextLast modified: September 28, 2016