reglab/housing_qa huggingface dataset:
TX Ins Code § 1369.362 (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 1369.362. Legislative Declaration

Sec. 1369.362.  LEGISLATIVE DECLARATION.  It is the intent of the legislature that, except with respect to the benefits excluded under Section 1369.352, the requirements contained in this subchapter apply to all health benefit plan issuers and pharmacy benefit managers unless otherwise prohibited by federal law.|Added by Acts 2015, 84th Leg., R.S., Ch. 596 (S.B. 332), Sec. 1, eff. January 1, 2016.|
TX Ins Code § 1369.401 (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 I. Pharmacy Benefit Claim Adjudication|Section 1369.401. Definition

Sec. 1369.401.  DEFINITION.  In this subchapter, "pharmacy benefit manager" has the meaning assigned by Section 4151.151.|Added by Acts 2015, 84th Leg., R.S., Ch. 10 (S.B. 94), Sec. 1, eff. September 1, 2015.|
TX Ins Code § 1369.402 (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 I. Pharmacy Benefit Claim Adjudication|Section 1369.402. Certain Fees Prohibited

Sec. 1369.402.  CERTAIN FEES PROHIBITED.  A health benefit plan issuer or a pharmacy benefit manager may not directly or indirectly charge or hold a pharmacist or pharmacy responsible for a fee for any step of or component or mechanism related to the claim adjudication process, including:(1)  the adjudication of a pharmacy benefit claim;(2)  the processing or transmission of a pharmacy benefit claim;(3)  the development or management of a claim processing or adjudication network; or(4)  participation in a claim processing or adjudication network.|Added by Acts 2015, 84th Leg., R.S., Ch. 10 (S.B. 94), Sec. 1, eff. September 1, 2015.|
TX Ins Code § 1369.451 (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 J. Coverage Related to Prescription Drug Synchronization|Section 1369.451. Definitions

Sec. 1369.451.  DEFINITIONS.  In this subchapter:(1)  "Cost-sharing amount" includes an amount charged for a deductible, coinsurance, or copayment.(2)  "Health care provider" means a person who provides health care services under a license, certificate, registration, or other similar evidence of regulation issued by this or another state of the United States.(3)  "Physician" means an individual licensed to practice medicine in this or another state of the United States.|Added by Acts 2017, 85th Leg., R.S., Ch. 1007 (H.B. 1296), Sec. 1, eff. September 1, 2017.|
TX Ins Code § 1369.452 (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 J. Coverage Related to Prescription Drug Synchronization|Section 1369.452. Applicability of Subchapter

Sec. 1369.452.  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 health maintenance organization operating under Chapter 843;(4)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844;(5)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846;(6)  a stipulated premium company operating under Chapter 884;(7)  a fraternal benefit society operating under Chapter 885; or(8)  an exchange operating under Chapter 942.(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 health benefit plan coverage provided under:(1)  Chapter 1551;(2)  Chapter 1575;(3)  Chapter 1579; and(4)  Chapter 1601.(d)  Notwithstanding Section 1501.251 or any other law, this subchapter applies to coverage under a small employer health benefit plan subject to Chapter 1501.(e)  This subchapter applies to a standard health benefit plan issued under Chapter 1507.(f)  To the extent allowed by federal law, the child health plan program operated under Chapter 62, Health and Safety Code, and the state Medicaid program, including the Medicaid managed care program operated under Chapter 533, Government Code, shall provide the coverage required under this subchapter to a recipient.|Added by Acts 2017, 85th Leg., R.S., Ch. 1007 (H.B. 1296), Sec. 1, eff. September 1, 2017.|
TX Ins Code § 1369.453 (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 J. Coverage Related to Prescription Drug Synchronization|Section 1369.453. Applicability to Certain Medications

Sec. 1369.453.  APPLICABILITY TO CERTAIN MEDICATIONS.  This subchapter applies with respect to only a medication that:(1)  is covered by the enrollee's health benefit plan;(2)  meets the prior authorization criteria specifically applicable to the medication under the health benefit plan on the date the request for synchronization is made;(3)  is used for treatment and management of a chronic illness, as that term is defined by Section 1369.456;(4)  may be prescribed with refills; (5)  is a formulation that can be effectively dispensed in accordance with the medication synchronization plan described by Section 1369.456; and(6)  is not, according to the schedules established by the commissioner of the Department of State Health Services under Chapter 481, Health and Safety Code:(A)  a Schedule II controlled substance; or(B)  a Schedule III controlled substance containing hydrocodone.|Added by Acts 2017, 85th Leg., R.S., Ch. 1007 (H.B. 1296), Sec. 1, eff. September 1, 2017.|
TX Ins Code § 1369.454 (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 J. Coverage Related to Prescription Drug Synchronization|Section 1369.454. Proration of Cost-Sharing Amount Required

Sec. 1369.454.  PRORATION OF COST-SHARING AMOUNT REQUIRED.  (a)  A health benefit plan that provides benefits for prescription drugs shall prorate any cost-sharing amount charged for a partial supply of a prescription drug if:(1)  the pharmacy or the enrollee's prescribing physician or health care provider notifies the health benefit plan that:(A)  the quantity dispensed is to synchronize the dates that the pharmacy dispenses the enrollee's prescription drugs; and(B)  the synchronization of the dates is in the best interest of the enrollee; and(2)  the enrollee agrees to the synchronization.(b)  The proration described by Subsection (a) must be based on the number of days' supply of the drug actually dispensed.|Added by Acts 2017, 85th Leg., R.S., Ch. 1007 (H.B. 1296), Sec. 1, eff. September 1, 2017.|
TX Ins Code § 1369.455 (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 J. Coverage Related to Prescription Drug Synchronization|Section 1369.455. Proration of Dispensing Fee Prohibited

Sec. 1369.455.  PRORATION OF DISPENSING FEE PROHIBITED.  A health benefit plan that prorates a cost-sharing amount as required by Section 1369.454 may not prorate the fee paid to the pharmacy for dispensing the drug for which the cost-sharing amount was prorated.|Added by Acts 2017, 85th Leg., R.S., Ch. 1007 (H.B. 1296), Sec. 1, eff. September 1, 2017.|
TX Ins Code § 1369.456 (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 J. Coverage Related to Prescription Drug Synchronization|Section 1369.456. Implementation of Certain Medication Synchronization Plans

Sec. 1369.456.  IMPLEMENTATION OF CERTAIN MEDICATION SYNCHRONIZATION PLANS.  (a)  For the purposes of this section:(1)  "Chronic illness" means an illness or physical condition that may be:(A)  reasonably expected to continue for an uninterrupted period of at least three months; and(B)  controlled but not cured by medical treatment.(2)  "Medication synchronization plan" means a plan established for the purpose of synchronizing the filling or refilling of multiple prescriptions.(b)  A health benefit plan shall establish a process through which the following parties may jointly approve a medication synchronization plan for medication to treat an enrollee's chronic illness:(1)  the health benefit plan;(2)  the enrollee;(3)  the prescribing physician or health care provider; and(4)  a pharmacist.(c)  A health benefit plan shall provide coverage for a medication dispensed in accordance with the dates established in the medication synchronization plan described by Subsection (b).(d)  A health benefit plan shall establish a process that allows a pharmacist or pharmacy to override the health benefit plan's denial of coverage for a medication described by Subsection (b).(e)  A health benefit plan shall allow a pharmacist or pharmacy to override the health benefit plan's denial of coverage through the process described by Subsection (d), and the health benefit plan shall provide coverage for the medication if:(1)  the prescription for the medication is being refilled in accordance with the medication synchronization plan described by Subsection (b); and(2)  the reason for the denial is that the prescription is being refilled before the date established by the plan's general prescription refill guidelines.|Added by Acts 2017, 85th Leg., R.S., Ch. 1007 (H.B. 1296), Sec. 1, eff. September 1, 2017.|
TX Ins Code § 1369.501 (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 K. Prescription Drug Cost Transparency|Section 1369.501. Definitions

Sec. 1369.501.  DEFINITIONS.  In this subchapter:(1)  "Animal health product" means a medical product approved and licensed for use in animal or veterinary medicine, including  a pharmaceutical, a biologic, an insecticide, and a parasiticide.(2)  "Health benefit plan" means an individual, blanket, or group plan, policy, or contract for health care services issued or delivered by a health benefit plan issuer in this state.(3)  "Health benefit plan issuer" means an insurance company, a health maintenance organization, or a hospital and medical service corporation.(4)  "Pharmaceutical drug manufacturer" means a person engaged in the business of producing, preparing, propagating, compounding, converting, processing, packaging, labeling, or distributing a prescription drug.  The term does not include a wholesale distributor or retailer of prescription drugs or a pharmacist licensed under Subtitle J, Title 3, Occupations Code.(5)  "Pharmacy benefit manager" has the meaning assigned by Section 4151.151.(6)  "Prescription drug" has the meaning assigned by Section 551.003, Occupations Code, except that the term "prescription drug" does not include a device or an animal health product.(7)  "Rebate" means a discount or concession that affects the price of a prescription drug to a pharmacy benefit manager or health benefit plan issuer for a prescription drug manufactured by the pharmaceutical drug manufacturer.(8)  "Specialty drug" means a prescription drug covered under Medicare Part D that exceeds the specialty tier cost threshold established by the Centers for Medicare and Medicaid Services.(9)  "Utilization management" means a set of formal techniques designed to monitor the use of, or evaluate the medical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures, or settings.|Added by Acts 2019, 86th Leg., R.S., Ch. 1291 (H.B. 2536), Sec. 2, eff. September 1, 2019.|
TX Ins Code § 1369.502 (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 K. Prescription Drug Cost Transparency|Section 1369.502. Pharmacy Benefit Manager Information

Sec. 1369.502.  PHARMACY BENEFIT MANAGER INFORMATION.  (a)  Not later than March 1 of each year, each pharmacy benefit manager shall file a report with the commissioner.  The report must state for the immediately preceding calendar year:(1)  the aggregated rebates, fees, price protection payments, and any other payments collected from pharmaceutical drug manufacturers; and(2)  the aggregated dollar amount of rebates, fees, price protection payments, and any other payments collected from pharmaceutical drug manufacturers that were:(A)  passed to:(i)  health benefit plan issuers; or(ii)  enrollees at the point of sale of a prescription drug; or(B)  retained as revenue by the pharmacy benefit manager.(a-1)  Notwithstanding Subsection (a), the report due not later than February 1, 2020, under that subsection must state the required information for the immediately preceding three calendar years in addition to stating the required information for the preceding calendar year.  This subsection expires September 1, 2021.(b)  A report submitted by a pharmacy benefit manager may not disclose the identity of a specific health benefit plan or enrollee, the price charged for a specific prescription drug or class of prescription drugs, or the amount of any rebate or fee provided for a specific prescription drug or class of prescription drugs.(c)  Not later than June 1 of each year, the commissioner shall publish the aggregated data from all reports for that year required by this section in an appropriate location on the department's Internet website.  The combined aggregated data from the reports must be published in a manner that does not disclose or tend to disclose proprietary or confidential information of any pharmacy benefit manager.|Added by Acts 2019, 86th Leg., R.S., Ch. 1291 (H.B. 2536), Sec. 2, eff. September 1, 2019.Amended by: Acts 2021, 87th Leg., R.S., Ch. 50 (H.B. 1033), Sec. 6, eff. September 1, 2021.|
TX Ins Code § 1369.503 (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 K. Prescription Drug Cost Transparency|Section 1369.503. Health Benefit Plan Issuer Information

Sec. 1369.503.  HEALTH BENEFIT PLAN ISSUER INFORMATION.  (a)  Not later than March 1 of each year, each health benefit plan issuer shall submit to the commissioner a report that states for the immediately preceding calendar year:(1)  the names of the 25 most frequently prescribed prescription drugs across all plans;(2)  the percent increase in annual net spending for prescription drugs across all plans;(3)  the percent increase in premiums that were attributable to prescription drugs across all plans;(4)  the percentage of specialty drugs with utilization management requirements across all plans; and(5)  the premium reductions that were attributable to specialty drug utilization management.(b)  A report submitted by a health benefit plan issuer may not disclose the identity of a specific health benefit plan or the price charged for a specific prescription drug or class of prescription drugs.(c)  Not later than June 1 of each year, the commissioner shall publish the aggregated data from all reports for that year required by this section in an appropriate location on the department's Internet website.  The combined aggregated data from the reports must be published in a manner that does not disclose or tend to disclose proprietary or confidential information of any health benefit plan issuer.|Added by Acts 2019, 86th Leg., R.S., Ch. 1291 (H.B. 2536), Sec. 2, eff. September 1, 2019.Amended by: Acts 2021, 87th Leg., R.S., Ch. 50 (H.B. 1033), Sec. 7, eff. September 1, 2021.|
TX Ins Code § 1369.5035 (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 K. Prescription Drug Cost Transparency|Section 1369.5035. Content of Reports

Sec. 1369.5035.  CONTENT OF REPORTS.  The reports required by Sections 1369.502 and 1369.503 must include information relating to private health benefit plans that cover prescription drugs and are regulated by the department.  The reports may not include information relating to:(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; or(2)  the medical assistance program under Chapter 32, Human Resources Code.|Added by Acts 2021, 87th Leg., R.S., Ch. 50 (H.B. 1033), Sec. 8, eff. September 1, 2021.|
TX Ins Code § 1369.504 (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 K. Prescription Drug Cost Transparency|Section 1369.504. Rules

Sec. 1369.504.  RULES.  The commissioner may adopt rules to implement this subchapter.|Added by Acts 2019, 86th Leg., R.S., Ch. 1291 (H.B. 2536), Sec. 2, eff. September 1, 2019.|Subchapter L, consisting of Secs. 1369.551 to 1369.560, was added by Acts 2021, 87th Leg., R.S., Ch. 142 (H.B. 1763), Sec. 1.For another Subchapter L, consisting of Secs. 1369.551 to 1369.555, added by Acts 2021, 87th Leg., R.S., Ch. 1012 (H.B. 1919), 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. Contracts With Pharmacists and Pharmacies|Section 1369.551. Definitions

Sec. 1369.551.  DEFINITIONS.  In this subchapter:(1)  "Pharmacy benefit manager" has the meaning assigned by Section 4151.151.(2)  "Pharmacy benefit network" means a network of pharmacies that have contracted with a pharmacy benefit manager to provide pharmacist services to enrollees.(3)  "Pharmacy services administrative organization" means an entity that contracts with a pharmacist or pharmacy to conduct on behalf of the pharmacist or pharmacy the pharmacist's or pharmacy's business with a third-party payor, including a pharmacy benefit manager, in connection with pharmacy benefits and to assist the pharmacist or pharmacy by providing administrative services, including negotiating, executing, and administering a contract with a third-party payor and communicating with the third-party payor in connection with a contract or pharmacy benefits.|Added by Acts 2021, 87th Leg., R.S., Ch. 142 (H.B. 1763), 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. Contracts With Pharmacists and Pharmacies|Section 1369.552. Applicability of Subchapter

Sec. 1369.552.  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 health maintenance organization operating under Chapter 843;(4)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844;(5)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846;(6)  a stipulated premium company operating under Chapter 884;(7)  a fraternal benefit society operating under Chapter 885;(8)  a Lloyd's plan operating under Chapter 941; or(9)  an exchange operating under Chapter 942.(b)  Notwithstanding any other law, this subchapter applies to:(1)  a small employer health benefit plan subject to Chapter 1501, including coverage provided through a health group cooperative under Subchapter B of that chapter;(2)  a standard health benefit plan issued under Chapter 1507;(3)  health benefits provided by or through a church benefits board under Subchapter I, Chapter 22, Business Organizations Code;(4)  group health coverage made available by a school district in accordance with Section 22.004, Education Code;(5)  a regional or local health care program operated under Section 75.104, Health and Safety Code; and(6)  a self-funded health benefit plan sponsored by a professional employer organization under Chapter 91, Labor Code.(c)  This subchapter does not apply to an issuer or provider of health benefits under or a pharmacy benefit manager administering pharmacy benefits under 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. 142 (H.B. 1763), 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. Contracts With Pharmacists and Pharmacies|Section 1369.553. Reduction of Certain Claim Payment Amounts Prohibited

Sec. 1369.553.  REDUCTION OF CERTAIN CLAIM PAYMENT AMOUNTS PROHIBITED.  (a)  A health benefit plan issuer or pharmacy benefit manager may not directly or indirectly reduce the amount of a claim payment to a pharmacist or pharmacy after adjudication of the claim through the use of an aggregated effective rate,  quality assurance program, other direct or indirect remuneration fee, or otherwise, except in accordance with an audit performed under Subchapter F.(b)  Nothing in this section prohibits a health benefit plan issuer or pharmacy benefit manager from increasing a claim payment amount after adjudication of the claim.|Added by Acts 2021, 87th Leg., R.S., Ch. 142 (H.B. 1763), Sec. 1, eff. September 1, 2021.|