Sec. 1369.056. ADVERSE DETERMINATION. (a) The refusal of a health benefit plan issuer to provide benefits to an enrollee for a prescription drug is an adverse determination for purposes of Section 4201.002 if:
(1) the drug is not included in a drug formulary used by the health benefit plan; and
(2) the enrollee's physician has determined that the drug is medically necessary.
(b) The enrollee may appeal the adverse determination under Subchapters H and I, Chapter 4201.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2G.012, eff. April 1, 2009.
Acts 2011, 82nd Leg., R.S., Ch. 501 (H.B. 1405), Sec. 7, eff. September 1, 2011.
Section: Previous 1369.053 1369.054 1369.0541 1369.0542 1369.0543 1369.0544 1369.055 1369.056 1369.057 1369.101 1369.102 1369.103 1369.104 1369.105 1369.106 NextLast modified: September 28, 2016