reglab/housing_qa huggingface dataset:
TX Ins Code § 1369.554 (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 L. Contracts With Pharmacists and Pharmacies|Section 1369.554. Reimbursement of Affiliated and Nonaffiliated Pharmacists and Pharmacies

Sec. 1369.554.  REIMBURSEMENT OF AFFILIATED AND NONAFFILIATED PHARMACISTS AND PHARMACIES.  (a)  In this section:(1)  "Affiliated pharmacist or pharmacy" means a pharmacist or pharmacy that directly, or indirectly through one or more intermediaries, controls or is controlled by, or is under common control with, a pharmacy benefit manager.(2)  "Nonaffiliated pharmacist or pharmacy" means a pharmacist or pharmacy that does not directly, or indirectly through one or more intermediaries, control and is not controlled by or under common control with a pharmacy benefit manager.(b)  A pharmacy benefit manager may not pay an affiliated pharmacist or pharmacy a reimbursement amount that is more than the amount the pharmacy benefit manager pays a nonaffiliated pharmacist or pharmacy for the same pharmacist service.|Added by Acts 2021, 87th Leg., R.S., Ch. 142 (H.B. 1763), Sec. 1, eff. September 1, 2021.|
TX Ins Code § 1369.555 (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 L. Contracts With Pharmacists and Pharmacies|Section 1369.555. Network Contract Fee Schedule

Sec. 1369.555.  NETWORK CONTRACT FEE SCHEDULE.  A pharmacy benefit network contract must specify or reference a separate fee schedule.  Unless otherwise available in the contract, the fee schedule must be provided electronically in an easily accessible and complete spreadsheet format and, on request, in writing to each contracted pharmacist and pharmacy.  The fee schedule must describe:(1)  specific services or procedures that the pharmacist or pharmacy may deliver and the amount of the corresponding payment;(2)  a methodology for calculating the amount of the payment based on a published fee schedule; or(3)  any other reasonable manner that provides an ascertainable amount for payment for services.|Added by Acts 2021, 87th Leg., R.S., Ch. 142 (H.B. 1763), Sec. 1, eff. September 1, 2021.|
TX Ins Code § 1369.556 (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 L. Contracts With Pharmacists and Pharmacies|Section 1369.556. Disclosure of Pharmacy Services Administrative Organization Contract

Sec. 1369.556.  DISCLOSURE OF PHARMACY SERVICES ADMINISTRATIVE ORGANIZATION CONTRACT.  A pharmacist or pharmacy that is a member of a pharmacy services administrative organization that enters into a contract with a health benefit plan issuer or pharmacy benefit manager on the pharmacist's or pharmacy's behalf is entitled to receive from the pharmacy services administrative organization a copy of the contract provisions applicable to the pharmacist or pharmacy, including each provision relating to the pharmacist's or pharmacy's rights and obligations under the contract.|Added by Acts 2021, 87th Leg., R.S., Ch. 142 (H.B. 1763), Sec. 1, eff. September 1, 2021.|
TX Ins Code § 1369.557 (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 L. Contracts With Pharmacists and Pharmacies|Section 1369.557. Delivery of Drugs

Sec. 1369.557.  DELIVERY OF DRUGS.  (a)  Except in a case in which the health benefit plan issuer or pharmacy benefit manager makes a credible allegation of fraud against the pharmacist or pharmacy and provides reasonable notice of the allegation and the basis of the allegation to the pharmacist or pharmacy, a health benefit plan issuer or pharmacy benefit manager may not as a condition of a contract with a pharmacist or pharmacy prohibit the pharmacist or pharmacy from:(1)  mailing or delivering a drug to a patient on the patient's request, to the extent permitted by law; or(2)  charging a shipping and handling fee to a patient requesting a prescription be mailed or delivered if the pharmacist or pharmacy discloses to the patient before the delivery:(A)  the fee that will be charged; and(B)  that the fee may not be reimbursable by the health benefit plan issuer or pharmacy benefit manager.(b)  A pharmacist or pharmacy may not charge a health benefit plan issuer or pharmacy benefit manager for the delivery of a prescription drug as described by this section unless the charge is specifically agreed to by the health benefit plan issuer or pharmacy benefit manager.|Added by Acts 2021, 87th Leg., R.S., Ch. 142 (H.B. 1763), Sec. 1, eff. September 1, 2021.|
TX Ins Code § 1369.558 (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 L. Contracts With Pharmacists and Pharmacies|Section 1369.558. Professional Standards and Scope of Practice Requirements

Sec. 1369.558.  PROFESSIONAL STANDARDS AND SCOPE OF PRACTICE REQUIREMENTS.  A health benefit plan issuer or pharmacy benefit manager may not as a condition of a contract with a pharmacist or pharmacy:(1)  require pharmacist or pharmacy accreditation standards or recertification requirements inconsistent with, more stringent than, or in addition to federal and state requirements; or(2)  prohibit a licensed pharmacist or pharmacy from dispensing any drug that may be dispensed under the pharmacist's or pharmacy's license unless:(A)  applicable state or federal law prohibits the pharmacist or pharmacy from dispensing the drug; or(B)  the manufacturer of the drug requires that a pharmacist or pharmacy possess one or more accreditations or certifications to dispense the drug and the pharmacist or pharmacy does not meet the requirement.|Added by Acts 2021, 87th Leg., R.S., Ch. 142 (H.B. 1763), Sec. 1, eff. September 1, 2021.|
TX Ins Code § 1369.559 (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 L. Contracts With Pharmacists and Pharmacies|Section 1369.559. Retaliation Prohibited

Sec. 1369.559.  RETALIATION PROHIBITED.  (a)  A pharmacy benefit manager may not retaliate against a pharmacist or pharmacy based on the pharmacist's or pharmacy's exercise of any right or remedy under this chapter.  Retaliation prohibited by this section includes:(1)  terminating or refusing to renew a contract with the pharmacist or pharmacy;(2)  subjecting the pharmacist or pharmacy to increased audits; or(3)  failing to promptly pay the pharmacist or pharmacy any money owed by the pharmacy benefit manager to the pharmacist or pharmacy.(b)  For purposes of this section, a pharmacy benefit manager is not considered to have retaliated against a pharmacist or pharmacy if the pharmacy benefit manager:(1)  takes an action in response to a credible allegation of fraud against the pharmacist or pharmacy; and(2)  provides reasonable notice to the pharmacist or pharmacy of the allegation of fraud and the basis of the allegation before taking the action.|Added by Acts 2021, 87th Leg., R.S., Ch. 142 (H.B. 1763), Sec. 1, eff. September 1, 2021.|
TX Ins Code § 1369.560 (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 L. Contracts With Pharmacists and Pharmacies|Section 1369.560. Waiver Prohibited

Sec. 1369.560.  WAIVER PROHIBITED.  The provisions of this subchapter may not be waived, voided, or nullified by contract.|Added by Acts 2021, 87th Leg., R.S., Ch. 142 (H.B. 1763), Sec. 1, eff. September 1, 2021.|Subchapter L, consisting of Secs. 1369.551 to 1369.555, was added by Acts 2021, 87th Leg., R.S., Ch. 1012 (H.B. 1919), Sec. 1.For another Subchapter L, consisting of Secs. 1369.551 to 1369.560, added by Acts 2021, 87th Leg., R.S., Ch. 142 (H.B. 1763), Sec. 1, see Sec. 1369.551 et seq., post.
TX Ins Code § 1369.551 (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 L. Affiliated Providers|Section 1369.551. Definitions

Sec. 1369.551.  DEFINITIONS.  In this subchapter:(1)  "Affiliated provider" means a pharmacy or durable medical equipment provider that directly, or indirectly through one or more intermediaries, controls, is controlled by, or is under common control with a health benefit plan issuer or pharmacy benefit manager.(2)  "Health benefit plan" has the meaning assigned by Section 1369.251.(3)  "Pharmacy benefit manager" has the meaning assigned by Section 4151.151.|Added by Acts 2021, 87th Leg., R.S., Ch. 1012 (H.B. 1919), Sec. 1, eff. September 1, 2021.|
TX Ins Code § 1369.552 (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 L. Affiliated Providers|Section 1369.552. Exceptions to Applicability of Subchapter

Sec. 1369.552.  EXCEPTIONS TO APPLICABILITY OF SUBCHAPTER.  Notwithstanding the definition of "health benefit plan" provided by Section 1369.551, 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 state Medicaid program, including the Medicaid managed care program operated under Chapter 533, Government Code;(2)  the child health plan program under Chapter 62, Health and Safety Code;(3)  the TRICARE military health system;(4)  a basic coverage plan under Chapter 1551;(5)  a basic plan under Chapter 1575;(6)  a coverage plan under Chapter 1579;(7)  a plan providing basic coverage under Chapter 1601; or(8)  a workers' compensation insurance policy or other form of providing medical benefits under Title 5, Labor Code.|Added by Acts 2021, 87th Leg., R.S., Ch. 1012 (H.B. 1919), Sec. 1, eff. September 1, 2021.|
TX Ins Code § 1369.553 (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 L. Affiliated Providers|Section 1369.553. Transfer or Acceptance of Certain Records Prohibited

Sec. 1369.553.  TRANSFER OR ACCEPTANCE OF CERTAIN RECORDS PROHIBITED.  (a)  In this section, "commercial purpose" does not include pharmacy reimbursement, formulary compliance, pharmaceutical care, utilization review by a health care provider, or a public health activity authorized by law.(b)  A health benefit plan issuer or pharmacy benefit manager may not transfer to or receive from the issuer's or manager's affiliated provider a record containing patient- or prescriber-identifiable prescription information for a commercial purpose.|Added by Acts 2021, 87th Leg., R.S., Ch. 1012 (H.B. 1919), Sec. 1, eff. September 1, 2021.|
TX Ins Code § 1369.554 (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 L. Affiliated Providers|Section 1369.554. Prohibition on Certain Communications

Sec. 1369.554.  PROHIBITION ON CERTAIN COMMUNICATIONS.  (a)  A health benefit plan issuer or pharmacy benefit manager may not steer or direct a patient to use the issuer's or manager's affiliated provider through any oral or written communication, including:(1)  online messaging regarding the provider; or(2)  patient- or prospective patient-specific advertising, marketing, or promotion of the provider.(b)  This section does not prohibit a health benefit plan issuer or pharmacy benefit manager from including the issuer's or manager's affiliated provider in a patient or prospective patient communication, if the communication:(1)  is regarding information about the cost or service provided by pharmacies or durable medical equipment providers in the network of a health benefit plan in which the patient or prospective patient is enrolled; and(2)  includes accurate comparable information regarding pharmacies or durable medical equipment providers in the network that are not the issuer's or manager's affiliated providers.|Added by Acts 2021, 87th Leg., R.S., Ch. 1012 (H.B. 1919), Sec. 1, eff. September 1, 2021.|
TX Ins Code § 1369.555 (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 L. Affiliated Providers|Section 1369.555. Prohibition on Certain Referrals and Solicitations

Sec. 1369.555.  PROHIBITION ON CERTAIN REFERRALS AND SOLICITATIONS.  (a)  A health benefit plan issuer or pharmacy benefit manager may not require a patient to use the issuer's or manager's affiliated provider in order for the patient to receive the maximum benefit for the service under the patient's health benefit plan.(b)  A health benefit plan issuer or pharmacy benefit manager may not offer or implement a health benefit plan that requires or induces a patient to use the issuer's or manager's affiliated provider, including by providing for reduced cost-sharing if the patient uses the affiliated provider.(c)  A health benefit plan issuer or pharmacy benefit manager may not solicit a patient or prescriber to transfer a patient prescription to the issuer's or manager's affiliated provider.(d)  A health benefit plan issuer or pharmacy benefit manager may not require a pharmacy or durable medical equipment provider that is not the issuer's or manager's affiliated provider to transfer a patient's prescription to the issuer's or manager's affiliated provider without the prior written consent of the patient.|Added by Acts 2021, 87th Leg., R.S., Ch. 1012 (H.B. 1919), Sec. 1, eff. September 1, 2021.|
TX Ins Code § 1377.001 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle E - Benefits Payable Under Health Coverages|Chapter 1377 - Coverage for Certain Amino Acid-Based Elemental Formulas|Subchapter A. General Provisions|Section 1377.001. Definition

Sec. 1377.001.  DEFINITION.  In this chapter, "enrollee" means an individual entitled to coverage under a health benefit plan.|Added by Acts 2009, 81st Leg., R.S., Ch. 1129 (H.B. 2000), Sec. 1, eff. September 1, 2009.|
TX Ins Code § 1377.002 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle E - Benefits Payable Under Health Coverages|Chapter 1377 - Coverage for Certain Amino Acid-Based Elemental Formulas|Subchapter A. General Provisions|Section 1377.002. Applicability of Chapter

Sec. 1377.002.  APPLICABILITY OF CHAPTER.  (a)  This chapter applies only to a health benefit plan, including a small employer health benefit plan written under Chapter 1501 or coverage provided by a health group cooperative under Subchapter B of that chapter, 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)  an exchange operating under Chapter 942;(6)  a Lloyd's plan operating under Chapter 941;(7)  a health maintenance organization operating under Chapter 843;(8)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846; or(9)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844.(b)  Notwithstanding any provision in Chapter 1551, 1575, 1579, or 1601 or any other law, this chapter 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.|Added by Acts 2009, 81st Leg., R.S., Ch. 1129 (H.B. 2000), Sec. 1, eff. September 1, 2009.|
TX Ins Code § 1377.003 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle E - Benefits Payable Under Health Coverages|Chapter 1377 - Coverage for Certain Amino Acid-Based Elemental Formulas|Subchapter A. General Provisions|Section 1377.003. Exception

Sec. 1377.003.  EXCEPTION.  This chapter does not apply to:(1)  a plan that provides coverage:(A)  only for benefits for a specified disease or  for another limited benefit, other than a plan that provides benefits for a disease or disorder listed in Section 1377.051(a);(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)  only for dental or vision care; or(F)  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)  a workers' compensation insurance policy;(4)  medical payment insurance coverage provided under an automobile insurance policy;(5)  a credit insurance policy;(6)  a limited benefit policy that does not provide coverage for physical examinations or wellness exams; or(7)  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 1377.002.|Added by Acts 2009, 81st Leg., R.S., Ch. 1129 (H.B. 2000), Sec. 1, eff. September 1, 2009.|
TX Ins Code § 1377.051 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle E - Benefits Payable Under Health Coverages|Chapter 1377 - Coverage for Certain Amino Acid-Based Elemental Formulas|Subchapter B. Coverage for Certain Amino Acid-Based Elemental Formulas|Section 1377.051. Required Coverage for Certain Amino Acid-Based Elemental Formulas

Sec. 1377.051.  REQUIRED COVERAGE FOR CERTAIN AMINO ACID-BASED ELEMENTAL FORMULAS.  (a)  A health benefit plan must provide coverage as provided by this chapter for amino acid-based elemental formulas, regardless of the formula delivery method, that are used for the diagnosis and treatment of:(1)  immunoglobulin E and non-immunoglobulin E mediated allergies to multiple food proteins;(2)  severe food protein-induced enterocolitis syndrome;(3)  eosinophilic disorders, as evidenced by the results of a biopsy; and(4)  impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract.(b)  Subject to Subsection (c), the coverage required under Subsection (a) is required if the treating physician has issued a written order stating that the amino acid-based elemental formula is medically necessary for the treatment of an enrollee who is diagnosed with a disease or disorder listed in Subsection (a). The coverage must include coverage of any medically necessary services associated with the administration of the formula.(c)  A health benefit plan must provide the coverage described by Subsection (a) on a basis no less favorable than the basis on which prescription drugs and other medications and related services are covered by the plan, and to the same extent that the plan provides coverage for drugs that are available only on the orders of a physician.|Added by Acts 2009, 81st Leg., R.S., Ch. 1129 (H.B. 2000), Sec. 1, eff. September 1, 2009.|
TX Ins Code § 1377.052 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle E - Benefits Payable Under Health Coverages|Chapter 1377 - Coverage for Certain Amino Acid-Based Elemental Formulas|Subchapter B. Coverage for Certain Amino Acid-Based Elemental Formulas|Section 1377.052. Utilization Review

Sec. 1377.052.  UTILIZATION REVIEW.  (a)  A utilization review agent acting on behalf of a health benefit plan issuer may review a treating physician's determination of the medical necessity of the use of an amino acid-based elemental formula for the treatment of an enrollee who is diagnosed with a disease or disorder listed in Section 1377.051(a).(b)  Utilization review under this section is subject to Chapter 4201.|Added by Acts 2009, 81st Leg., R.S., Ch. 1129 (H.B. 2000), Sec. 1, eff. September 1, 2009.|
TX Ins Code § 1379.001 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle E - Benefits Payable Under Health Coverages|Chapter 1379 - Coverage for Routine Patient Care Costs for Enrollees Participating in Certain Clinical Trials|Subchapter A. General Provisions|Section 1379.001. Definitions

Sec. 1379.001.  DEFINITIONS.  In this chapter:(1)  "Enrollee" means an individual entitled to coverage under a health benefit plan.(2)  "Life-threatening disease or condition" means a disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted.(3)  "Research institution" means the institution or other person or entity conducting a phase I, phase II, phase III, or phase IV clinical trial.|Added by Acts 2009, 81st Leg., R.S., Ch. 719 (S.B. 39), Sec. 1, eff. September 1, 2009.|