CHAPTER 1369. BENEFITS RELATED TO PRESCRIPTION DRUGS AND DEVICES AND RELATED SERVICES

State Codes and Statutes

Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1369-benefits-related-to-prescription-drugs-and-devices-and-related-services

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE E. BENEFITS PAYABLE UNDER HEALTH COVERAGES

CHAPTER 1369. BENEFITS RELATED TO PRESCRIPTION DRUGS AND DEVICES

AND RELATED SERVICES

SUBCHAPTER A. COVERAGE OF PRESCRIPTION DRUGS IN GENERAL

Sec. 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 because of the presence of a disease condition in

the patient for whom the drug is prescribed; or

(B) a clinically significant adverse effect of a prescribed drug

on a disease condition of the patient for whom the drug is

prescribed.

(2) "Drug" has the meaning assigned by Section 551.003,

Occupations Code.

(3) "Indication" means a symptom, cause, or occurrence in a

disease that points out the cause, diagnosis, course of

treatment, or prognosis of the disease.

(4) "Peer-reviewed medical literature" means scientific studies

published in a peer-reviewed national professional journal.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 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, accident, or sickness, including an individual, group,

blanket, or franchise insurance policy or insurance agreement, a

group hospital service contract, or an individual or group

evidence of coverage or similar coverage document that is offered

by:

(1) an insurance company;

(2) a group hospital service corporation operating under Chapter

842;

(3) a fraternal benefit society operating under Chapter 885;

(4) a stipulated premium company operating under Chapter 884;

(5) a reciprocal exchange operating under Chapter 942;

(6) a health maintenance organization operating under Chapter

843;

(7) a multiple employer welfare arrangement that holds a

certificate of authority under Chapter 846; or

(8) an approved nonprofit health corporation that holds a

certificate of authority under Chapter 844.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 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;

(B) only for accidental death or dismemberment;

which an employee is absent from work because of sickness or

injury;

(D) as a supplement to a liability insurance policy;

(E) for credit insurance;

(F) only for dental or vision care;

(G) only for hospital expenses; or

(H) only for indemnity for hospital confinement;

(2) a small employer health benefit plan written under Chapter

1501;

(3) a Medicare supplemental policy as defined by Section

1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss), as

amended;

(4) a workers' compensation insurance policy;

(5) medical payment insurance coverage provided under a motor

vehicle insurance policy; or

(6) a long-term care insurance policy, including a nursing home

fixed indemnity policy, unless the commissioner determines that

the policy provides benefit coverage so comprehensive that the

policy is a health benefit plan as described by Section 1369.002.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

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.

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.

Sec. 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.

SUBCHAPTER B. COVERAGE OF PRESCRIPTION DRUGS SPECIFIED BY DRUG

FORMULARY

Sec. 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 benefit plan issuer approves payment; or

incentives for physicians to prescribe.

(2) "Enrollee" means an individual who is covered under a group

health benefit plan, including a covered dependent.

(3) "Physician" means a person licensed as a physician by the

Texas State Board of Medical Examiners.

(4) "Prescription drug" has the meaning assigned by Section

551.003, Occupations Code.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1369.052. APPLICABILITY OF SUBCHAPTER. This subchapter

applies only to a group health benefit plan that provides

benefits for medical or surgical expenses incurred as a result of

a health condition, accident, or sickness, including a group,

blanket, or franchise insurance policy or insurance agreement, a

group hospital service contract, or a group contract or similar

coverage document that is offered by:

(1) an insurance company;

(2) a group hospital service corporation operating under Chapter

842;

(3) a fraternal benefit society operating under Chapter 885;

(4) a stipulated premium company operating under Chapter 884;

(5) a reciprocal exchange operating under Chapter 942;

(6) a health maintenance organization operating under Chapter

843;

(7) a multiple employer welfare arrangement that holds a

certificate of authority under Chapter 846; or

(8) an approved nonprofit health corporation that holds a

certificate of authority under Chapter 844.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 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;

(B) only for accidental death or dismemberment;

which an employee is absent from work because of sickness or

injury;

(D) as a supplement to a liability insurance policy;

(E) for credit insurance;

(F) only for dental or vision care;

(G) only for hospital expenses; or

(H) only for indemnity for hospital confinement;

(2) a small employer health benefit plan written under Chapter

1501;

(3) a Medicare supplemental policy as defined by Section

1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss), as

amended;

(4) a workers' compensation insurance policy;

(5) medical payment insurance coverage provided under a motor

vehicle insurance policy; or

(6) a long-term care insurance policy, including a nursing home

fixed indemnity policy, unless the commissioner determines that

the policy provides benefit coverage so comprehensive that the

policy is a health benefit plan as described by Section 1369.052.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1369.054. NOTICE AND DISCLOSURE OF CERTAIN INFORMATION

REQUIRED. An issuer of a group health benefit plan that covers

prescription drugs and uses one or more drug formularies to

specify the prescription drugs covered under the plan shall:

(1) provide in plain language in the coverage documentation

provided to each enrollee:

(A) notice that the plan uses one or more drug formularies;

(B) an explanation of what a drug formulary is;

determine the prescription drugs to be included in or excluded

from a drug formulary;

(D) a statement of how often the issuer reviews the contents of

each drug formulary; and

(E) notice that an enrollee may contact the issuer to determine

whether a specific drug is included in a particular drug

formulary;

(2) disclose to an individual on request, not later than the

third business day after the date of the request, whether a

specific drug is included in a particular drug formulary; and

(3) notify an enrollee and any other individual who requests

information under this section that the inclusion of a drug in a

drug formulary does not guarantee that an enrollee's health care

provider will prescribe that drug for a particular medical

condition or mental illness.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1369.055. CONTINUATION OF COVERAGE REQUIRED; OTHER DRUGS

NOT PRECLUDED. (a) An issuer of a group health benefit plan

that covers prescription drugs shall offer to each enrollee at

the contracted benefit level and until the enrollee's plan

renewal date any prescription drug that was approved or covered

under the plan for a medical condition or mental illness,

regardless of whether the drug has been removed from the health

benefit plan's drug formulary before the plan renewal date.

(b) This section does not prohibit a physician or other health

professional who is authorized to prescribe a drug from

prescribing a drug that is an alternative to a drug for which

continuation of coverage is required under Subsection (a) if the

alternative drug is:

(1) covered under the group health benefit plan; and

(2) medically appropriate for the enrollee.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

For expiration of this section, see Subsection (c).

Sec. 1369.0551. STUDY. (a) The department shall conduct a

study to evaluate the ways in which pharmacy benefit managers use

prescription drug information to manage therapeutic drug

interchange programs and other drug substitution recommendations

made by pharmacy benefit managers or other similar entities. The

study must include information regarding pharmacy benefit

managers:

(1) intervening in the delivery or transmission of a

prescription from a prescribing health care practitioner to a

pharmacist for purposes of influencing the prescribing health

care practitioner's choice of therapy;

(2) recommending that a prescribing health care practitioner

change from the originally prescribed medication to another

medication, including generic substitutions and therapeutic

interchanges;

(3) changing a drug or device prescribed by a health care

practitioner without the consent of the prescribing health care

practitioner;

(4) changing a patient cost-sharing obligation for the cost of a

prescription drug or device, including placing a drug or device

on a higher formulary tier than the initial contracted benefit

level; and

(5) removing a drug or device from a group health benefit plan

formulary without providing proper enrollee notice.

(b) Not later than August 1, 2010, the department shall submit

to the governor, the lieutenant governor, the speaker of the

house of representatives, and the appropriate standing committees

of the legislature a report regarding the results of the study

required by Subsection (a), together with any recommendations for

legislation.

Added by Acts 2009, 81st Leg., R.S., Ch.

1033, Sec. 1, eff. September 1, 2009.

Added by Acts 2009, 81st Leg., R.S., Ch.

1207, Sec. 2, eff. September 1, 2009.

Sec. 1369.056. ADVERSE DETERMINATION. (a) The refusal of a

group 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

group 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, Sec. 2G.012, eff. April 1, 2009.

Sec. 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.

SUBCHAPTER C. COVERAGE OF PRESCRIPTION CONTRACEPTIVE DRUGS AND

DEVICES AND RELATED SERVICES

Sec. 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,

examination, procedure, or medical service that is provided on an

outpatient basis and that is related to the use of a drug or

device intended to prevent pregnancy.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 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 or surgical expenses incurred as a result of

a health condition, accident, or sickness, including an

individual, group, blanket, or franchise insurance policy or

insurance agreement, a group hospital service contract, or an

individual or group evidence of coverage or similar coverage

document that is offered by:

(1) an insurance company;

(2) a group hospital service corporation operating under Chapter

842;

(3) a fraternal benefit society operating under Chapter 885;

(4) a stipulated premium company operating under Chapter 884;

(5) a reciprocal exchange operating under Chapter 942;

(6) a health maintenance organization operating under Chapter

843;

(7) a multiple employer welfare arrangement that holds a

certificate of authority under Chapter 846; or

(8) an approved nonprofit health corporation that holds a

certificate of authority under Chapter 844.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 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 other

than for cancer;

(B) for accidental death or dismemberment;

which an employee is absent from work because of sickness or

injury;

(D) as a supplement to a liability insurance policy;

(E) for credit insurance;

(F) for dental or vision care; or

(G) for indemnity for hospital confinement;

(2) a Medicare supplemental policy as defined by Section

1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss), as

amended;

(3) a workers' compensation insurance policy;

(4) medical payment insurance coverage provided under a motor

vehicle insurance policy; or

(5) a long-term care insurance policy, including a nursing home

fixed indemnity policy, unless the commissioner determines that

the policy provides benefit coverage so comprehensive that the

policy is a health benefit plan as described by Section 1369.102.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 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 contraceptive drug or device approved by the

United States Food and Drug Administration; or

(2) an outpatient contraceptive service.

(b) This section does not prohibit a limitation that applies to

all prescription drugs or devices or all services for which

benefits are provided under a health benefit plan.

abortifacients or any other drug or device that terminates a

pregnancy.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 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 unless

the amount of the required cost-sharing is the same as or less

than the amount of the required cost-sharing applicable to

benefits for other prescription drugs or devices under the plan.

(b) A health benefit plan may not impose a deductible,

copayment, coinsurance, or other cost-sharing provision

applicable to benefits for outpatient contraceptive services

unless the amount of the required cost-sharing is the same as or

less than the amount of the required cost-sharing applicable to

benefits for other outpatient services under the plan.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 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 the same as or shorter than any waiting

period applicable to benefits for other prescription drugs or

devices under the plan.

(b) A health benefit plan may not impose a waiting period

applicable to benefits for outpatient contraceptive services

unless the waiting period is the same as or shorter than any

waiting period applicable to benefits for other outpatient

services under the plan.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 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 device or

an outpatient contraceptive service, deny:

(A) the eligibility of an applicant to enroll in the plan;

(B) the continued eligibility of an enrollee for coverage under

the plan; or

plan;

(2) provide a monetary incentive to an applicant for enrollment

or an enrollee to induce the applicant or enrollee to accept

coverage that does not satisfy the requirements of this

subchapter; or

(3) reduce or limit a payment to a health care professional, or

otherwise penalize the professional, because the professional

prescribes a contraceptive drug or device or provides an

outpatient contraceptive service.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 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 health care provider

providing medical or health care services under the plan to

offer, recommend, offer advice concerning, pay for, provide,

assist in, perform, arrange, or participate in providing or

performing a medical or health care service that violates the

religious convictions of the organization, unless the

prescription contraceptive coverage is necessary to preserve the

life or health of the enrollee.

(b) An issuer of a health benefit plan that excludes or limits

coverage for medical or health care services under this section

shall state the exclusion or limitation in:

(1) the plan's coverage document;

(2) the plan's statement of benefits;

(3) plan brochures; and

(4) other informational materials for the plan.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 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 Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

SUBCHAPTER D. PHARMACY BENEFIT CARDS

Sec. 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 condition, accident, or sickness, including an

individual, group, blanket, or franchise insurance policy or

insurance agreement, a group hospital service contract, or an

individual or group evidence of coverage or similar coverage

document that is offered by:

(1) an insurance company;

(2) a group hospital service corporation operating under Chapter

842;

(3) a fraternal benefit society operating under Chapter 885;

(4) a stipulated premium company operating under Chapter 884;

(5) a reciprocal exchange operating under Chapter 942;

(6) a health maintenance organization operating under Chapter

843;

(7) a multiple employer welfare arrangement that holds a

certificate of authority under Chapter 846; or

(8) an approved nonprofit health corporation that holds a

certificate of authority under Chapter 844.

(b) Notwithstanding any other law, this subchapter applies to

coverage under:

(1) the basic coverage plan under Chapter 1551;

(2) the basic plan under Chapter 1575;

(3) the primary care coverage plan under Chapter 1579;

(4) the basic coverage plan under Chapter 1601;

(5) the child health plan program under Chapter 62, Health and

Safety Code; and

(6) the medical assistance program under Chapter 32, Human

Resources Code.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

1117, Sec. 1, eff. September 1, 2009.

Sec. 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;

(B) only for accidental death or dismemberment;

which an employee is absent from work because of sickness or

injury;

(D) as a supplement to a liability insurance policy;

(E) for credit insurance;

(F) only for dental or vision care;

(G) only for hospital expenses; or

(H) only for indemnity for hospital confinement;

(2) a small employer health benefit plan written under Chapter

1501;

(3) a Medicare supplemental policy as defined by Section

1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);

(4) a workers' compensation insurance policy;

(5) medical payment insurance coverage provided under a motor

vehicle insurance policy; or

(6) a long-term care insurance policy, including a nursing home

fixed indemnity policy, unless the commissioner determines that

the policy provides benefit coverage so comprehensive that the

policy is a health benefit plan as described by Section 1369.151.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 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 enrollee:

(1) the name of the entity administering the pharmacy benefits

if the entity is different from the health benefit plan issuer;

(2) the group number applicable to the enrollee;

(3) the identification number of the enrollee, which may not be

the enrollee's social security number;

(4) the bank identification number necessary for electronic

billing;

(5) the effective date of the coverage evidenced by the card;

and

(6) copayment information for generic and brand-name

prescription drugs.

(b) In addition to the information required under Subsection

(a), the issuer of a health benefit plan shall include on the

identification card of each enrollee:

(1) the logo of the entity administering the pharmacy benefits

if the entity is different from the health benefit plan issuer;

and

(2) a telephone number for contacting an appropriate person to

obtain information relating to the pharmacy benefits provided

under the plan.

issuer of a health benefit plan may provide the information

required under Subsections (a) and (b) in electronically readable

form on the back of the identification card.

(d) This section does not require a health benefit plan issuer

that administers its own pharmacy benefits to issue an

identification card separate from any identification card issued

to an enrollee to evidence coverage under the plan if the

identification card issued to evidence coverage contains the

information required by Subsections (a) and (b).

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

1117, Sec. 2, eff. September 1, 2009.

Sec. 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 by the Workgroup for Electronic

Data Interchange or by other similar organizations recognized by

the commissioner.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

1117, Sec. 3, eff. September 1, 2009.

State Codes and Statutes

State Codes and Statutes

State Codes and Statutes

State Codes and Statutes

Loading..

Loading, Please Wait!