2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1451 - Access to Certain Practitioners and Facilities › Subchapter C. Selection of Practitioners › Section 1451.1261. Reimbursement for Certain Services and Procedures Performed by Pharmacists

Sec. 1451.1261.  REIMBURSEMENT FOR CERTAIN SERVICES AND PROCEDURES PERFORMED BY PHARMACISTS.  (a)  Notwithstanding any other law, in addition to applying to a policy, agreement, or contract described by Section 1451.102, this section applies to any other individual or group health benefit plan that provides benefits described by Section 1451.102, including:
(1)  a health benefit plan issued by:
(A)  a group hospital service corporation operating under Chapter 842;
(B)  a health maintenance organization operating under Chapter 843; or
(C)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846;
(2)  a small employer health benefit plan subject to Chapter 1501;
(3)  a standard health benefit plan issued under Chapter 1507;
(4)  health benefits provided by or through a church benefits board under Subchapter I, Chapter 22, Business Organizations 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.
Text of subsection effective until April 01, 2025
(b)  This section does not apply 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;
(4)  a plan providing basic coverage under Chapter 1601;
(5)  the state Medicaid program, including the Medicaid managed care program operated under Chapter 533, Government Code; or
(6)  the child health plan program under Chapter 62, Health and Safety Code.
Text of subsection effective on April 01, 2025
(b)  This section does not apply 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;
(4)  a plan providing basic coverage under Chapter 1601;
(5)  the state Medicaid program, including the Medicaid managed care program operated under Chapters 540 and 540A, Government Code; or
(6)  the child health plan program under Chapter 62, Health and Safety Code.
(c)  Notwithstanding Section 1451.102, this section applies to coverage under a group health benefit plan provided to a resident of this state regardless of whether the group policy, agreement, or contract is delivered, issued for delivery, or renewed in this state.
(d)  An insurer or other health benefit plan issuer or a third-party administrator or pharmacy benefit manager of a health benefit plan may not deny reimbursement to a pharmacist for the provision of a service or procedure within the scope of the pharmacist's license to practice pharmacy under Subtitle J, Title 3, Occupations Code, that:
(1)  would be covered by the insurance policy or other coverage agreement if the service or procedure were provided by:
(A)  a physician;
(B)  an advanced practice nurse; or
(C)  a physician assistant; and
(2)  is performed by the pharmacist in strict compliance with laws and rules related to:
(A)  the provision of the service or procedure; and
(B)  the pharmacist's license.
(e)  This section may not be construed to require an insurer or other health benefit plan issuer or a third-party administrator or pharmacy benefit manager to reimburse a pharmacist or pharmacy as an in-network or preferred provider.
Added by Acts 2019, 86th Leg., R.S., Ch. 324 (H.B. 3441), Sec. 1, eff. September 1, 2019.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.131, eff. April 1, 2025.