reglab/housing_qa huggingface dataset:
TX Ins Code § 1369.266 (2021)
2021 Texas Statutes|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 F. Audits of Pharmacists and Pharmacies|Section 1369.266. Recoupment and Interest Charged After Audit

Sec. 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 pharmacy an amount based only on a final audit report; and(2)  may not accrue or assess interest on an amount due until the date the pharmacist or pharmacy receives the final audit report under Section 1369.264.(b)  The limitations on recoupment and interest accrual or assessment under Subsection (a) do not apply to a health benefit plan issuer or pharmacy benefit manager that, after reviewing claims data, written or oral statements of pharmacy staff, wholesalers, or others, or other investigative information, including patient referrals, anonymous reports, or postings on Internet websites, suspects the audited pharmacist or pharmacy committed fraud or made an intentional misrepresentation related to the pharmacy business.|Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.|
TX Ins Code § 1369.267 (2021)
2021 Texas Statutes|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 F. Audits of Pharmacists and Pharmacies|Section 1369.267. Waiver Prohibited

Sec. 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), Sec. 1, eff. September 1, 2013.|
TX Ins Code § 1369.268 (2021)
2021 Texas Statutes|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 F. Audits of Pharmacists and Pharmacies|Section 1369.268. Remedies Not Exclusive

Sec. 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., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.|
TX Ins Code § 1369.269 (2021)
2021 Texas Statutes|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 F. Audits of Pharmacists and Pharmacies|Section 1369.269. Enforcement; Rules

Sec. 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 Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.|
TX Ins Code § 1369.270 (2021)
2021 Texas Statutes|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 F. Audits of Pharmacists and Pharmacies|Section 1369.270. Legislative Declaration

Sec. 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 to providers who are pharmacists or pharmacies apply to all health benefit plan issuers and pharmacy benefit managers unless otherwise prohibited by federal law.|Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.|
TX Ins Code § 1369.301 (2021)
2021 Texas Statutes|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 G. Standard Request Form for Prior Authorization of Prescription Drug Benefits|Section 1369.301. Definition

Sec. 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), Sec. 1, eff. September 1, 2013.Redesignated from Insurance Code, Section 1369.251 by Acts 2015, 84th Leg., R.S., Ch. 1236 (S.B. 1296), Sec. 21.001(38), eff. September 1, 2015.|
TX Ins Code § 1369.302 (2021)
2021 Texas Statutes|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 G. Standard Request Form for Prior Authorization of Prescription Drug Benefits|Section 1369.302. Applicability of Subchapter

Sec. 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 condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or a small or large employer 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.(b)  This subchapter applies to group health coverage made available by a school district in accordance with Section 22.004, Education Code.(c)  Notwithstanding any provision in Chapter 1551, 1575, 1579, or 1601 or any other law, this subchapter applies to:(1)  a basic coverage plan under Chapter 1551;(2)  a basic plan under Chapter 1575;(3)  a primary care coverage plan under Chapter 1579; and(4)  basic coverage under Chapter 1601.(d)  Notwithstanding any other law, this subchapter applies to coverage under:(1)  the child health plan program under Chapter 62, Health and Safety Code, or the health benefits plan for children under Chapter 63, Health and Safety Code; and(2)  the medical assistance program under Chapter 32, Human Resources Code.|Added by Acts 2013, 83rd Leg., R.S., Ch. 1328 (S.B. 644), Sec. 1, eff. September 1, 2013.Redesignated from Insurance Code, Section 1369.252 by Acts 2015, 84th Leg., R.S., Ch. 1236 (S.B. 1296), Sec. 21.001(38), eff. September 1, 2015.|
TX Ins Code § 1369.303 (2021)
2021 Texas Statutes|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 G. Standard Request Form for Prior Authorization of Prescription Drug Benefits|Section 1369.303. Exception

Sec. 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;(B)  only for accidental death or dismemberment;(C)  for wages or payments in lieu of wages for a period during 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 Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);(3)  medical payment insurance coverage provided under a motor vehicle insurance policy;(4)  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 1369.302;(5)  health and accident coverage provided by a risk pool created under Chapter 172, Local Government Code; or(6)  a workers' compensation insurance policy.|Added by Acts 2013, 83rd Leg., R.S., Ch. 1328 (S.B. 644), Sec. 1, eff. September 1, 2013.Redesignated from Insurance Code, Section 1369.253 by Acts 2015, 84th Leg., R.S., Ch. 1236 (S.B. 1296), Sec. 21.001(38), eff. September 1, 2015.Amended by: Acts 2015, 84th Leg., R.S., Ch. 1236 (S.B. 1296), Sec. 21.002(14), eff. September 1, 2015.|
TX Ins Code § 1369.304 (2021)
2021 Texas Statutes|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 G. Standard Request Form for Prior Authorization of Prescription Drug Benefits|Section 1369.304. Standard Form

Sec. 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 plan issuer or the agent of the health benefit plan issuer that manages or administers prescription drug benefits to use the form for any prior authorization of prescription drug benefits required by the plan;(3)  require that the department and a health benefit plan issuer or the agent of the health benefit plan issuer that manages or administers prescription drug benefits make the form available electronically on the website of:(A)  the department;(B)  the health benefit plan issuer; and(C)  the agent of the health benefit plan issuer; and(4)  establish penalties for failure to accept the form and acknowledge receipt of the form as required by commissioner rule.(b)  Not later than the second anniversary of the date national standards for electronic prior authorization of benefits are adopted, a health benefit plan issuer or the agent of the health benefit plan issuer that manages or administers prescription drug benefits shall exchange prior authorization requests electronically with a prescribing provider who has e-prescribing capability and who initiates a request electronically.(c)  In prescribing a form under this section, the commissioner shall:(1)  develop the form with input from the advisory committee on uniform prior authorization forms established under Section 1369.305; and(2)  take into consideration:(A)  any form for requesting prior authorization of benefits that is widely used in this state or any form currently used by the department;(B)  request forms for prior authorization of benefits established by the federal Centers for Medicare and Medicaid Services; and(C)  national standards, or draft standards, pertaining to electronic prior authorization of benefits.|Added by Acts 2013, 83rd Leg., R.S., Ch. 1328 (S.B. 644), Sec. 1, eff. September 1, 2013.Redesignated from Insurance Code, Section 1369.254 by Acts 2015, 84th Leg., R.S., Ch. 1236 (S.B. 1296), Sec. 21.001(38), eff. September 1, 2015.Amended by: Acts 2015, 84th Leg., R.S., Ch. 1236 (S.B. 1296), Sec. 21.002(15), eff. September 1, 2015.|
TX Ins Code § 1369.306 (2021)
2021 Texas Statutes|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 G. Standard Request Form for Prior Authorization of Prescription Drug Benefits|Section 1369.306. Failure to Use or Acknowledge Standard Form

Sec. 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 or accept the form prescribed under this subchapter or fails to acknowledge the receipt of a completed form submitted by a prescribing provider, as required by commissioner rule, the health benefit plan issuer or the agent of the health benefit plan issuer is subject to the penalties established by the commissioner.|Added by Acts 2013, 83rd Leg., R.S., Ch. 1328 (S.B. 644), Sec. 1, eff. September 1, 2013.Redesignated from Insurance Code, Section 1369.256 by Acts 2015, 84th Leg., R.S., Ch. 1236 (S.B. 1296), Sec. 21.001(38), eff. September 1, 2015.|
TX Ins Code § 1369.351 (2021)
2021 Texas Statutes|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 H. Maximum Allowable Cost|Section 1369.351. Definitions

Sec. 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 Legislature, Regular Session, 2013.(2)  "Pharmacy benefit manager" has the meaning assigned by Section 4151.151.|Added by Acts 2015, 84th Leg., R.S., Ch. 596 (S.B. 332), Sec. 1, eff. January 1, 2016.|
TX Ins Code § 1369.352 (2021)
2021 Texas Statutes|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 H. Maximum Allowable Cost|Section 1369.352. Certain Benefits Excluded

Sec. 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 Code;(2)  a Medicaid program operated under Chapter 32, Human Resources Code;(3)  the child health plan program under Chapter 62, Health and Safety Code;(4)  the health benefits plan for children under Chapter 63, Health and Safety Code;(5)  a health benefit plan issued under Chapter 1551, 1575, 1579, or 1601; or(6)  a workers' compensation insurance policy or other form of providing medical benefits under Title 5, Labor Code.|Added by Acts 2015, 84th Leg., R.S., Ch. 596 (S.B. 332), Sec. 1, eff. January 1, 2016.|
TX Ins Code § 1369.353 (2021)
2021 Texas Statutes|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 H. Maximum Allowable Cost|Section 1369.353. Criteria for Drugs on Maximum Allowable Cost Lists

Sec. 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)  has an "A" or "B" rating in the most recent version of the United States Food and Drug Administration's Approved Drug Products with Therapeutic Equivalence Evaluations, also known as the Orange Book; or(B)  is rated "NR" or "NA" or has a similar rating by a nationally recognized reference; and(2)  the drug is:(A)  generally available for purchase by pharmacists and pharmacies in this state from a national or regional wholesaler; and(B)  not obsolete.|Added by Acts 2015, 84th Leg., R.S., Ch. 596 (S.B. 332), Sec. 1, eff. January 1, 2016.|
TX Ins Code § 1369.354 (2021)
2021 Texas Statutes|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 H. Maximum Allowable Cost|Section 1369.354. Formulation of Maximum Allowable Costs; Disclosures

Sec. 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 of that drug and any drug listed as therapeutically equivalent to that drug in the most recent version of the United States Food and Drug Administration's Approved Drug Products with Therapeutic Equivalence Evaluations, also known as the Orange Book.(b)  Notwithstanding Subsection (a), if a therapeutically equivalent generic drug is unavailable or has limited market presence, a health benefit plan issuer or pharmacy benefit manager may place on a maximum allowable cost list a drug that has:(1)  a "B" rating in the most recent version of the United States Food and Drug Administration's Approved Drug Products with Therapeutic Equivalence Evaluations, also known as the Orange Book; or(2)  an "NR" or "NA" rating or a similar rating by a nationally recognized reference.(c)  A health benefit plan issuer or pharmacy benefit manager must, in accordance with Subsection (d), disclose to a pharmacist or pharmacy the sources of the pricing data used in formulating maximum allowable cost prices.(d)  The information described by Subsection (c) must be disclosed:(1)  on the date the health benefit plan issuer or pharmacy benefit manager enters into the contract with the pharmacist or pharmacy; and(2)  after that contract date, on the request of the pharmacist or pharmacy.|Added by Acts 2015, 84th Leg., R.S., Ch. 596 (S.B. 332), Sec. 1, eff. January 1, 2016.|
TX Ins Code § 1369.355 (2021)
2021 Texas Statutes|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 H. Maximum Allowable Cost|Section 1369.355. Updates

Sec. 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 cost lists or modify maximum allowable cost prices to remain consistent with changes in pricing data used in formulating maximum allowable cost prices and product availability.(b)  A health benefit plan issuer or pharmacy benefit manager shall review and update maximum allowable cost price information for each drug at least once every seven days to reflect any modification of maximum allowable cost pricing.|Added by Acts 2015, 84th Leg., R.S., Ch. 596 (S.B. 332), Sec. 1, eff. January 1, 2016.|
TX Ins Code § 1369.356 (2021)
2021 Texas Statutes|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 H. Maximum Allowable Cost|Section 1369.356. Access to Maximum Allowable Cost Lists

Sec. 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 pharmacy benefit manager a process to readily access the maximum allowable cost list that applies to the pharmacist or pharmacy.|Added by Acts 2015, 84th Leg., R.S., Ch. 596 (S.B. 332), Sec. 1, eff. January 1, 2016.|
TX Ins Code § 1369.357 (2021)
2021 Texas Statutes|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 H. Maximum Allowable Cost|Section 1369.357. Appeal From Maximum Allowable Cost Price Determination

Sec. 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 or pharmacy to appeal a maximum allowable cost price of a drug on or before the 10th day after the date a pharmacy benefit claim for the drug is made.(b)  The health benefit plan issuer or pharmacy benefit manager shall respond to an appeal described by Subsection (a) in a documented communication not later than the 10th day after the date the appeal is received by the health benefit plan issuer or pharmacy benefit manager.(c)  If the appeal is successful, the health benefit plan issuer or pharmacy benefit manager shall:(1)  adjust the maximum allowable cost price that is the subject of the appeal effective on the day after the date the appeal is decided;(2)  apply the adjusted maximum allowable cost price to all similarly situated pharmacists and pharmacies as determined by the health benefit plan issuer or pharmacy benefit manager; and(3)  allow the pharmacist or pharmacy that succeeded in the appeal to reverse and rebill the pharmacy benefit claim giving rise to the appeal.(d)  If the appeal is not successful, the health benefit plan issuer or pharmacy benefit manager shall disclose to the pharmacist or pharmacy:(1)  each reason the appeal is denied; and(2)  the national drug code number from the national or regional wholesalers from which the drug is generally available for purchase by pharmacists and pharmacies in this state at the maximum allowable cost price that is the subject of the appeal.|Added by Acts 2015, 84th Leg., R.S., Ch. 596 (S.B. 332), Sec. 1, eff. January 1, 2016.|
TX Ins Code § 1369.358 (2021)
2021 Texas Statutes|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 H. Maximum Allowable Cost|Section 1369.358. Confidentiality of Maximum Allowable Cost List

Sec. 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 is confidential.  This section may not be construed to alter a health benefit plan issuer's or pharmacy benefit manager's obligations under Section 1369.356.|Added by Acts 2015, 84th Leg., R.S., Ch. 596 (S.B. 332), Sec. 1, eff. January 1, 2016.|
TX Ins Code § 1369.359 (2021)
2021 Texas Statutes|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 H. Maximum Allowable Cost|Section 1369.359. Waiver Prohibited

Sec. 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), Sec. 1, eff. January 1, 2016.|
TX Ins Code § 1369.360 (2021)
2021 Texas Statutes|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 H. Maximum Allowable Cost|Section 1369.360. Remedies Not Exclusive

Sec. 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., Ch. 596 (S.B. 332), Sec. 1, eff. January 1, 2016.|
TX Ins Code § 1369.361 (2021)
2021 Texas Statutes|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 H. Maximum Allowable Cost|Section 1369.361. Enforcement

Sec. 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.|