SUBCHAPTER A COVERAGE OF PRESCRIPTION DRUGS IN GENERAL
- Texas Section 1369.001 - Definitions
In this subchapter: (1) "Contraindication" means the potential for, or the occurrence of: (A) an undesirable change in the therapeutic effect of a prescribed drug...
- Texas Section 1369.002 - Applicability Of Subchapter
This subchapter applies only to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition,...
- Texas Section 1369.003 - Exception
This subchapter does not apply to: (1) a health benefit plan that provides coverage: (A) only for a specified disease or for another limited benefit;...
- Texas Section 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...
SUBCHAPTER B COVERAGE OF PRESCRIPTION DRUGS SPECIFIED BY DRUG FORMULARY
- Texas Section 1369.005 - Rules
The commissioner may adopt rules to implement this subchapter. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
- Texas Section 1369.051 - Definitions
In this subchapter: (1) "Drug formulary" means a list of drugs: (A) for which a health benefit plan provides coverage; (B) for which a health...
- Texas Section 1369.052 - Applicability Of Subchapter
This subchapter applies only to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition,...
- Texas Section 1369.053 - Exception
This subchapter does not apply to: (1) a health benefit plan that provides coverage: (A) only for a specified disease or for another single benefit;...
- Texas Section 1369.054 - Notice And Disclosure Of Certain Information Required
An issuer of a health benefit plan that covers prescription drugs and uses one or more drug formularies to specify the prescription drugs covered under...
- Texas Section 1369.0541 - Modification Of Drug Coverage Under Plan
(a) A health benefit plan issuer may modify drug coverage provided under a health benefit plan if: (1) the modification occurs at the time of...
- Texas Section 1369.0542 - Formulary Information On Internet Website
(a) A health benefit plan issuer shall display on a public Internet website maintained by the issuer formulary information as required by the commissioner by...
- Texas Section 1369.0543 - Formulary Disclosure Requirements
(a) The commissioner shall develop and adopt by rule requirements to promote consistency and clarity in the disclosure of formularies to facilitate comparison shopping among...
- Texas Section 1369.0544 - Formulary Information Provided By Toll-free Telephone Number
In addition to providing the information described by Section 1369.0543(d)(1), a health benefit plan issuer may make the information available to enrollees, prospective enrollees, and...
- Texas Section 1369.055 - Continuation Of Coverage Required; Other Drugs Not Precluded
(a) An issuer of a health benefit plan that covers prescription drugs shall offer to each enrollee at the contracted benefit level and until the...
- Texas Section 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...
SUBCHAPTER C COVERAGE OF PRESCRIPTION CONTRACEPTIVE DRUGS AND DEVICES AND RELATED SERVICES
- Texas Section 1369.057 - Rules
The commissioner may adopt rules to implement this subchapter. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
- Texas Section 1369.101 - Definitions
In this subchapter: (1) "Enrollee" means a person who is entitled to benefits under a health benefit plan. (2) "Outpatient contraceptive service" means a consultation,...
- Texas Section 1369.102 - Applicability Of Subchapter
This subchapter applies only to a health benefit plan, including a small employer health benefit plan written under Chapter 1501, that provides benefits for medical...
- Texas Section 1369.103 - Exception
This subchapter does not apply to: (1) a health benefit plan that provides coverage only: (A) for a specified disease or for another limited benefit...
- Texas Section 1369.104 - Exclusion Or Limitation Prohibited
(a) A health benefit plan that provides benefits for prescription drugs or devices may not exclude or limit benefits to enrollees for: (1) a prescription...
- Texas Section 1369.105 - Certain Cost-sharing Provisions Prohibited
(a) A health benefit plan may not impose a deductible, copayment, coinsurance, or other cost-sharing provision applicable to benefits for prescription contraceptive drugs or devices...
- Texas Section 1369.106 - Certain Waiting Periods Prohibited
(a) A health benefit plan may not impose a waiting period applicable to benefits for prescription contraceptive drugs or devices unless the waiting period is...
- Texas Section 1369.107 - Prohibited Conduct
A health benefit plan issuer may not: (1) solely because of the applicant's or enrollee's use or potential use of a prescription contraceptive drug or...
- Texas Section 1369.108 - Exemption For Entities Associated With Religious Organization
(a) This subchapter does not require a health benefit plan that is issued by an entity associated with a religious organization or any physician or...
SUBCHAPTER D PHARMACY BENEFIT CARDS
- Texas Section 1369.109 - Enforcement
A health benefit plan issuer that violates this subchapter is subject to the enforcement provisions of Subtitle B, Title 2. Added by Acts 2003, 78th...
- Texas Section 1369.151 - Applicability Of Subchapter
(a) This subchapter applies only to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health...
- Texas Section 1369.152 - Exception
This subchapter does not apply to: (1) a health benefit plan that provides coverage: (A) only for a specified disease or for another limited benefit;...
- Texas Section 1369.153 - Information Required On Identification Card
(a) An issuer of a health benefit plan that provides pharmacy benefits to enrollees shall include on the front of the identification card of each...
SUBCHAPTER E COVERAGE FOR ORALLY ADMINISTERED ANTICANCER MEDICATIONS
- Texas Section 1369.154 - Rules
(a) The commissioner shall adopt rules as necessary to implement this subchapter. (b) Rules adopted by the commissioner must be consistent with national standards established...
- Texas Section 1369.201 - Definitions
In this subchapter: (1) "Health benefit exchange" means an American Health Benefit Exchange administered by the federal government or created pursuant to Section 1311(b), Patient...
- Texas Section 1369.202 - Applicability Of Subchapter
This subchapter applies only to a health benefit plan, including a small employer health benefit plan written under Chapter 1501 or coverage provided by a...
- Texas Section 1369.203 - Exception
(a) This subchapter does not apply to: (1) a plan that provides coverage: (A) only for fixed indemnity benefits for a specified disease or diseases;...
SUBCHAPTER F AUDITS OF PHARMACISTS AND PHARMACIES
- Texas Section 1369.204 - Required Coverage For Orally Administered Anticancer Medications
(a) A health benefit plan that provides coverage for cancer treatment must provide coverage for a prescribed, orally administered anticancer medication that is used to...
- Texas Section 1369.251 - Definitions
In this subchapter: (1) "Desk audit" means an audit conducted by a health benefit plan issuer or pharmacy benefit manager at a location other than...
- Texas Section 1369.252 - Exceptions To Applicability Of Subchapter
This subchapter does not apply to an issuer or provider of health benefits under or a pharmacy benefit manager administering pharmacy benefits under: (1) the...
- Texas Section 1369.254 - Audit Of Pharmacist Or Pharmacy; Notice; General Provisions
(a) Except as provided by Subsection (d), a health benefit plan issuer or pharmacy benefit manager that performs an on-site audit under this subchapter of...
- Texas Section 1369.255 - Completion Of Audit
An audit of a claim under Section 1369.254 must be completed on or before the one-year anniversary of the date the claim is received by...
- Texas Section 1369.256 - Audit Requiring Professional Judgment
A health benefit plan issuer or pharmacy benefit manager that conducts an on-site audit or a desk audit involving a pharmacist's clinical or professional judgment...
- Texas Section 1369.257 - Access To Pharmacy Area
A health benefit plan issuer or pharmacy benefit manager that conducts an on-site audit may not enter the pharmacy area unless escorted by an individual...
- Texas Section 1369.258 - Validation Using Certain Records Authorized
A pharmacist or pharmacy that is being audited may: (1) validate a prescription, refill of a prescription, or change in a prescription with a prescription...
- Texas Section 1369.259 - Calculation Of Recoupment; Use Of Extrapolation Prohibited
(a) A health benefit plan issuer or pharmacy benefit manager may not calculate the amount of a recoupment based on: (1) an absence of documentation...
- Texas Section 1369.260 - Clerical Or Recordkeeping Error; Fraud Allegation
(a) An unintentional clerical or recordkeeping error, such as a typographical error, scrivener's error, or computer error, found during an on-site audit or a desk...
- Texas Section 1369.261 - Access To Previous Audit Reports; Uniform Audit Standards
(a) Except as provided by Subsection (b), a health benefit plan issuer or pharmacy benefit manager may have access to an audit report of a...
- Texas Section 1369.262 - Compensation Of Auditor
An individual performing an on-site audit or a desk audit may not directly or indirectly receive compensation based on a percentage of the amount recovered...
- Texas Section 1369.263 - Conclusion Of Audit; Summary; Preliminary Audit Report
(a) At the conclusion of an on-site audit or a desk audit, the health benefit plan issuer or pharmacy benefit manager shall: (1) provide to...
- Texas Section 1369.264 - Final Audit Report
Not later than the 120th day after the date the pharmacist or pharmacy receives a preliminary audit report under Section 1369.263, the health benefit plan...
- Texas Section 1369.265 - Certain Audits Exempt From Deadlines
A health benefit plan issuer or pharmacy benefit manager is not subject to the deadlines for sending a report under Sections 1369.263 and 1369.264 if,...
- Texas Section 1369.266 - Recoupment And Interest Charged After Audit
(a) If an audit under this subchapter is conducted, the health benefit plan issuer or pharmacy benefit manager: (1) may recoup from the pharmacist or...
- Texas Section 1369.267 - Waiver Prohibited
The provisions of this subchapter may not be waived, voided, or nullified by contract. Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358),...
- Texas Section 1369.268 - Remedies Not Exclusive
This subchapter may not be construed to waive a remedy at law available to a pharmacist or pharmacy. Added by Acts 2013, 83rd Leg., R.S.,...
- Texas Section 1369.269 - Enforcement; Rules
The commissioner may enforce this subchapter and adopt and enforce reasonable rules necessary to accomplish the purposes of this subchapter. Added by Acts 2013, 83rd...
SUBCHAPTER G STANDARD REQUEST FORM FOR PRIOR AUTHORIZATION OF PRESCRIPTION DRUG BENEFITS
- Texas Section 1369.270 - Legislative Declaration
Except as provided by Section 1369.252, it is the intent of the legislature that the requirements contained in this subchapter regarding the audit of claims...
- Texas Section 1369.301 - Definition
In this subchapter, "prescription drug" has the meaning assigned by Section 551.003, Occupations Code. Added by Acts 2013, 83rd Leg., R.S., Ch. 1328 (S.B. 644),...
- Texas Section 1369.302 - Applicability Of Subchapter
(a) This subchapter applies only to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health...
- Texas Section 1369.303 - Exception
This subchapter does not apply to: (1) a health benefit plan that provides coverage: (A) only for a specified disease or for another single benefit;...
- Texas Section 1369.304 - Standard Form
(a) The commissioner by rule shall: (1) prescribe a single, standard form for requesting prior authorization of prescription drug benefits; (2) require a health benefit...
- Texas Section 1369.305 - Advisory Committee On Uniform Prior Authorization Forms
(a) The commissioner shall appoint a committee to advise the commissioner on the technical, operational, and practical aspects of developing the single, standard prior authorization...
SUBCHAPTER H MAXIMUM ALLOWABLE COST
- Texas Section 1369.306 - Failure To Use Or Acknowledge Standard Form
If a health benefit plan issuer or the agent of the health benefit plan issuer that manages or administers prescription drug benefits fails to use...
- Texas Section 1369.351 - Definitions
In this subchapter: (1) "Health benefit plan" has the meaning assigned by Section 1369.251, as added by Chapter 915 (H.B. 1358), Acts of the 83rd...
- Texas Section 1369.352 - Certain Benefits Excluded
This subchapter does not apply to maximum allowable costs for pharmacy benefits provided under: (1) a Medicaid managed care program operated under Chapter 533, Government...
- Texas Section 1369.353 - Criteria For Drugs On Maximum Allowable Cost Lists
A health benefit plan issuer or pharmacy benefit manager may not include a drug on a maximum allowable cost list unless: (1) the drug: (A)...
- Texas Section 1369.354 - Formulation Of Maximum Allowable Costs; Disclosures
(a) In formulating the maximum allowable cost price for a drug, a health benefit plan issuer or pharmacy benefit manager may only use the price...
- Texas Section 1369.355 - Updates
(a) A health benefit plan issuer or pharmacy benefit manager shall establish a process that will in a timely manner eliminate drugs from maximum allowable...
- Texas Section 1369.356 - Access To Maximum Allowable Cost Lists
A health benefit plan issuer or pharmacy benefit manager must provide to each pharmacist or pharmacy under contract with the health benefit plan issuer or...
- Texas Section 1369.357 - Appeal From Maximum Allowable Cost Price Determination
(a) A health benefit plan issuer or pharmacy benefit manager must provide in the contract with each pharmacist or pharmacy a procedure for the pharmacist...
- Texas Section 1369.358 - Confidentiality Of Maximum Allowable Cost List
A maximum allowable cost list that applies to a pharmacist or pharmacy and is maintained by a health benefit plan issuer or pharmacy benefit manager...
- Texas Section 1369.359 - Waiver Prohibited
The provisions of this subchapter may not be waived, voided, or nullified by contract. Added by Acts 2015, 84th Leg., R.S., Ch. 596 (S.B. 332),...
- Texas Section 1369.360 - Remedies Not Exclusive
This subchapter may not be construed to waive a remedy at law available to a pharmacist or pharmacy. Added by Acts 2015, 84th Leg., R.S.,...
- Texas Section 1369.361 - Enforcement
The commissioner shall enforce this subchapter. Added by Acts 2015, 84th Leg., R.S., Ch. 596 (S.B. 332), Sec. 1, eff. January 1, 2016.
SUBCHAPTER I PHARMACY BENEFIT CLAIM ADJUDICATION
- Texas Section 1369.362 - Legislative Declaration
It is the intent of the legislature that, except with respect to the benefits excluded under Section 1369.352, the requirements contained in this subchapter apply...
- Texas Section 1369.401 - Definition
In this subchapter, "pharmacy benefit manager" has the meaning assigned by Section 4151.151. Added by Acts 2015, 84th Leg., R.S., Ch. 10 (S.B. 94), Sec....
- Texas Section 1369.402 - Certain Fees Prohibited
A health benefit plan issuer or a pharmacy benefit manager may not directly or indirectly charge or hold a pharmacist or pharmacy responsible for a...