reglab/housing_qa huggingface dataset:
TX Ins Code § 1369.051 (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 B. Coverage of Prescription Drugs Specified by Drug Formulary|Section 1369.051. Definitions

Sec. 1369.051.  DEFINITIONS.  In this subchapter:(1)  "Clinical practice guideline" means a statement systematically developed by a multidisciplinary panel of experts composed of physicians and, as necessary, other health care providers to assist a patient or health care provider in making a decision about appropriate health care for a specific clinical circumstance or condition.(1-a)  "Clinical review criteria" means the written screening procedures, decision abstracts, clinical protocols, and clinical practice guidelines used by a health benefit plan issuer, utilization review organization, or independent review organization to determine the medical necessity and appropriateness or the experimental or investigational nature of a health care service or prescription drug.(1-b)  "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(C)  that a health benefit plan issuer encourages or offers incentives for physicians to prescribe.(2)  "Enrollee" means an individual who is covered under a 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.(5)  "Step therapy protocol" means a protocol that requires an enrollee to use a prescription drug or sequence of prescription drugs other than the drug that the enrollee's physician recommends for the enrollee's treatment before the health benefit plan provides coverage for the recommended drug.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2011, 82nd Leg., R.S., Ch. 501 (H.B. 1405), Sec. 1, eff. September 1, 2011.Acts 2017, 85th Leg., R.S., Ch. 103 (S.B. 680), Sec. 1, eff. September 1, 2017.|
TX Ins Code § 1369.052 (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 B. Coverage of Prescription Drugs Specified by Drug Formulary|Section 1369.052. Applicability of Subchapter

Sec. 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, 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.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2011, 82nd Leg., R.S., Ch. 501 (H.B. 1405), Sec. 2, eff. September 1, 2011.|
TX Ins Code § 1369.053 (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 B. Coverage of Prescription Drugs Specified by Drug Formulary|Section 1369.053. Exception

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;(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), as amended;(3)  a workers' compensation insurance policy;(4)  medical payment insurance coverage provided under a motor vehicle insurance policy;(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 1369.052;(6)  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; or(7)  a Medicaid managed care program operated under Chapter 533, Government Code, or a Medicaid program operated under Chapter 32, Human Resources Code.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2011, 82nd Leg., R.S., Ch. 501 (H.B. 1405), Sec. 3, eff. September 1, 2011.|
TX Ins Code § 1369.054 (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 B. Coverage of Prescription Drugs Specified by Drug Formulary|Section 1369.054. Notice and Disclosure of Certain Information Required

Sec. 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 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;(C)  a statement regarding the method the issuer uses to 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.Amended by: Acts 2011, 82nd Leg., R.S., Ch. 501 (H.B. 1405), Sec. 4, eff. September 1, 2011.|
TX Ins Code § 1369.0541 (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 B. Coverage of Prescription Drugs Specified by Drug Formulary|Section 1369.0541. Modification of Drug Coverage Under Plan

Sec. 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 coverage renewal;(2)  the modification is effective uniformly among all group health benefit plan sponsors covered by identical or substantially identical health benefit plans or all individuals covered by identical or substantially identical individual health benefit plans, as applicable; and(3)  not later than the 60th day before the date the modification is effective, the issuer provides written notice of the modification to the commissioner, each affected group health benefit plan sponsor, each affected enrollee in an affected group health benefit plan, and each affected individual health benefit plan holder.(b)  Modifications affecting drug coverage that require notice under Subsection (a) include:(1)  removing a drug from a formulary;(2)  adding a requirement that an enrollee receive prior authorization for a drug;(3)  imposing or altering a quantity limit for a drug;(4)  imposing a step-therapy restriction for a drug; and(5)  moving a drug to a higher cost-sharing tier unless a generic drug alternative to the drug is available.(c)  A health benefit plan issuer may elect to offer an enrollee in the plan the option of receiving notifications required by this section by e-mail.|Added by Acts 2011, 82nd Leg., R.S., Ch. 501 (H.B. 1405), Sec. 5, eff. September 1, 2011.|
TX Ins Code § 1369.0545 (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 B. Coverage of Prescription Drugs Specified by Drug Formulary|Section 1369.0545. Step Therapy Protocols

Sec. 1369.0545.  STEP THERAPY PROTOCOLS.  (a)  A health benefit plan issuer that requires a step therapy protocol before providing coverage for a prescription drug must establish, implement, and administer the step therapy protocol in accordance with clinical review criteria readily available to the health care industry.  The health benefit plan issuer shall take into account the needs of atypical patient populations and diagnoses in establishing the clinical review criteria.  The clinical review criteria:(1)  must consider generally accepted clinical practice guidelines that are:(A)  developed and endorsed by a multidisciplinary panel of experts described by Subsection (b);(B)  based on high quality studies, research, and medical practice;(C)  created by an explicit and transparent process that:(i)  minimizes bias and conflicts of interest;(ii)  explains the relationship between treatment options and outcomes;(iii)  rates the quality of the evidence supporting the recommendations; and(iv)  considers relevant patient subgroups and preferences; and(D)  updated at appropriate intervals after a review of new evidence, research, and treatments; or(2)  if clinical practice guidelines described by Subdivision (1) are not reasonably available, may be based on peer-reviewed publications developed by independent experts, which may include physicians, with expertise applicable to the relevant health condition.(b)  A multidisciplinary panel of experts composed of physicians and, as necessary, other health care providers that develops and endorses clinical practice guidelines under Subsection (a)(1) must manage conflicts of interest by:(1)  requiring each member of the panel's writing or review group to:(A)  disclose any potential conflict of interest, including a conflict of interest involving an insurer, health benefit plan issuer, or pharmaceutical manufacturer; and(B)  recuse himself or herself in any situation in which the member has a conflict of interest;(2)  using a methodologist to work with writing groups to provide objectivity in data analysis and the ranking of evidence by preparing evidence tables and facilitating consensus; and(3)  offering an opportunity for public review and comment.(c)  Subsection (b) does not apply to a panel or committee of experts, including a pharmacy and therapeutics committee, established by a health benefit plan issuer or a pharmacy benefit manager that advises the health benefit plan issuer or pharmacy benefit manager regarding drugs or formularies.|Added by Acts 2017, 85th Leg., R.S., Ch. 103 (S.B. 680), Sec. 2, eff. September 1, 2017.|
TX Ins Code § 1369.055 (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 B. Coverage of Prescription Drugs Specified by Drug Formulary|Section 1369.055. Continuation of Coverage Required; Other Drugs Not Precluded

Sec. 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 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 health benefit plan; and(2)  medically appropriate for the enrollee.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2011, 82nd Leg., R.S., Ch. 501 (H.B. 1405), Sec. 6, eff. September 1, 2011.|
TX Ins Code § 1369.056 (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 B. Coverage of Prescription Drugs Specified by Drug Formulary|Section 1369.056. Adverse Determination

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.|
TX Ins Code § 1369.057 (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 B. Coverage of Prescription Drugs Specified by Drug Formulary|Section 1369.057. Rules

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.|
TX Ins Code § 1369.076 (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 B. -1. Transparency Requirements for Certain Individual Health Benefit Plans|Section 1369.076. Definitions

Sec. 1369.076.  DEFINITIONS.  In this subchapter, terms defined by Subchapter B have the meanings assigned by that subchapter.|Added by Acts 2017, 85th Leg., R.S., Ch. 135 (H.B. 1227), Sec. 1, eff. September 1, 2017.|
TX Ins Code § 1369.077 (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 B. -1. Transparency Requirements for Certain Individual Health Benefit Plans|Section 1369.077. Applicability of Subchapter

Sec. 1369.077.  APPLICABILITY OF SUBCHAPTER.  This subchapter applies only to an individual health benefit plan to which Subchapter B applies.|Added by Acts 2017, 85th Leg., R.S., Ch. 135 (H.B. 1227), Sec. 1, eff. September 1, 2017.|
TX Ins Code § 1369.078 (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 B. -1. Transparency Requirements for Certain Individual Health Benefit Plans|Section 1369.078. Formulary Information on Internet Website

Sec. 1369.078.  FORMULARY INFORMATION ON INTERNET WEBSITE.  (a)  A health benefit plan issuer shall display on a public Internet website maintained by the issuer formulary information for each of the issuer's individual health benefit plans as required by the commissioner by rule.(b)  A direct electronic link to the formulary information must be displayed in a conspicuous manner in the electronic summary of benefits and coverage of each individual health benefit plan issued by the health benefit plan issuer on the health benefit plan issuer's Internet website.  The information must be publicly accessible to enrollees, prospective enrollees, and others without necessity of providing a password, a user name, or personally identifiable information.|Added by Acts 2015, 84th Leg., R.S., Ch. 1038 (H.B. 1624), Sec. 1, eff. September 1, 2015.Transferred, redesignated and amended from Insurance Code, Section 1369.0542 by Acts 2017, 85th Leg., R.S., Ch. 135 (H.B. 1227), Sec. 2, eff. September 1, 2017.|
TX Ins Code § 1369.079 (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 B. -1. Transparency Requirements for Certain Individual Health Benefit Plans|Section 1369.079. Formulary Disclosure Requirements

Sec. 1369.079.  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 individual health benefit plans.(b)  The requirements adopted under Subsection (a) must apply to each prescription drug:(1)  included in a formulary and dispensed in a network pharmacy; or(2)  covered under an individual health benefit plan and typically administered by a physician or health care provider.(c)  The formulary disclosures must:(1)  be electronically searchable by drug name;(2)  include for each drug the information required by Subsection (d) in the order listed in that subsection; and(3)  indicate each formulary that applies to each individual health benefit plan issued by the issuer.(d)  The formulary disclosures must include for each drug:(1)  the cost-sharing amount for each drug, including as applicable:(A)  the dollar amount of a copayment; or(B)  for a drug subject to coinsurance:(i)  an enrollee's cost-sharing amount stated in dollars; or(ii)  a cost-sharing range, denoted as follows:(a)  under $100 - $;(b)  $100-$250 - $$;(c)  $251-$500 - $$$;(d)  $501-$1,000 - $$$$; or(e)  over $1,000 - $$$$$;(2)  a disclosure of prior authorization, step therapy, or other protocol requirements for each drug;(3)  if the individual health benefit plan uses a tier-based formulary, the specific tier for each drug listed in the formulary;(4)  a description of how prescription drugs will specifically be included in or excluded from the deductible, including a description of out-of-pocket costs for a prescription drug that may not apply to the deductible;(5)  identification of preferred formulary drugs; and(6)  an explanation of coverage of each formulary drug.(e)  The commissioner by rule may allow an alternative method of making disclosures required under Subsection (d)(1) relating to cost-sharing through a web-based tool that must:(1)  be publicly accessible to enrollees, prospective enrollees, and others without necessity of providing a password, a user name, or personally identifiable information;(2)  allow consumers to electronically search formulary information by the name under which the individual health benefit plan is marketed; and(3)  be accessible through a direct link that is displayed on each page of the formulary disclosure that lists each drug as required under Subsection (c).|Added by Acts 2015, 84th Leg., R.S., Ch. 1038 (H.B. 1624), Sec. 1, eff. September 1, 2015.Transferred, redesignated and amended from Insurance Code, Section 1369.0543 by Acts 2017, 85th Leg., R.S., Ch. 135 (H.B. 1227), Sec. 2, eff. September 1, 2017.|
TX Ins Code § 1369.080 (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 B. -1. Transparency Requirements for Certain Individual Health Benefit Plans|Section 1369.080. Formulary Information Provided by Toll-Free Telephone Number

Sec. 1369.080.  FORMULARY INFORMATION PROVIDED BY TOLL-FREE TELEPHONE NUMBER.  In addition to providing the information described by Section 1369.079(d)(1) in the manner required by Section 1369.079, a health benefit plan issuer may make the information available to enrollees, prospective enrollees, and others through a toll-free telephone number that operates at least during normal business hours.|Added by Acts 2015, 84th Leg., R.S., Ch. 1038 (H.B. 1624), Sec. 1, eff. September 1, 2015.Transferred, redesignated and amended from Insurance Code, Section 1369.0544 by Acts 2017, 85th Leg., R.S., Ch. 135 (H.B. 1227), Sec. 2, eff. September 1, 2017.|
TX Ins Code § 1369.101 (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 C. Coverage of Prescription Contraceptive Drugs and Devices and Related Services|Section 1369.101. Definitions

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.|