reglab/statecodes huggingface dataset:
2023 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.
(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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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

Text of section effective until April 01, 2025
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.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.129, eff. April 1, 2025.
2023 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

Text of section effective on April 01, 2025
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 Chapters 540 and 540A, 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.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.129, eff. April 1, 2025.
2023 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.
2023 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.
2023 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.
2023 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 M. Contracts With Pharmacists and Pharmacies › Section 1369.601. Definitions

Sec. 1369.601.  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.
Redesignated from Insurance Code, Section 1369.551 by Acts 2023, 88th Leg., R.S., Ch. 768 (H.B. 4595), Sec. 24.001(27), eff. September 1, 2023.
2023 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 M. Contracts With Pharmacists and Pharmacies › Section 1369.602. Applicability of Subchapter

Sec. 1369.602.  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.
Redesignated from Insurance Code, Section 1369.552 by Acts 2023, 88th Leg., R.S., Ch. 768 (H.B. 4595), Sec. 24.001(27), eff. September 1, 2023.
2023 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 M. Contracts With Pharmacists and Pharmacies › Section 1369.603. Reduction of Certain Claim Payment Amounts Prohibited

Sec. 1369.603.  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.
Redesignated from Insurance Code, Section 1369.553 by Acts 2023, 88th Leg., R.S., Ch. 768 (H.B. 4595), Sec. 24.001(27), eff. September 1, 2023.
2023 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 M. Contracts With Pharmacists and Pharmacies › Section 1369.604. Reimbursement of Affiliated and Nonaffiliated Pharmacists and Pharmacies

Sec. 1369.604.  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.
Redesignated from Insurance Code, Section 1369.554 by Acts 2023, 88th Leg., R.S., Ch. 768 (H.B. 4595), Sec. 24.001(27), eff. September 1, 2023.
2023 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 M. Contracts With Pharmacists and Pharmacies › Section 1369.605. Network Contract Fee Schedule

Sec. 1369.605.  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.
Redesignated from Insurance Code, Section 1369.555 by Acts 2023, 88th Leg., R.S., Ch. 768 (H.B. 4595), Sec. 24.001(27), eff. September 1, 2023.
2023 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 M. Contracts With Pharmacists and Pharmacies › Section 1369.606. Disclosure of Pharmacy Services Administrative Organization Contract

Sec. 1369.606.  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.
Redesignated from Insurance Code, Section 1369.556 by Acts 2023, 88th Leg., R.S., Ch. 768 (H.B. 4595), Sec. 24.001(27), eff. September 1, 2023.
2023 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 M. Contracts With Pharmacists and Pharmacies › Section 1369.607. Delivery of Drugs

Sec. 1369.607.  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.
Redesignated from Insurance Code, Section 1369.557 by Acts 2023, 88th Leg., R.S., Ch. 768 (H.B. 4595), Sec. 24.001(27), eff. September 1, 2023.
2023 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 M. Contracts With Pharmacists and Pharmacies › Section 1369.608. Professional Standards and Scope of Practice Requirements

Sec. 1369.608.  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.
Redesignated from Insurance Code, Section 1369.558 by Acts 2023, 88th Leg., R.S., Ch. 768 (H.B. 4595), Sec. 24.001(27), eff. September 1, 2023.
2023 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 M. Contracts With Pharmacists and Pharmacies › Section 1369.609. Retaliation Prohibited

Sec. 1369.609.  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.
Redesignated from Insurance Code, Section 1369.559 by Acts 2023, 88th Leg., R.S., Ch. 768 (H.B. 4595), Sec. 24.001(27), eff. September 1, 2023.
2023 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 M. Contracts With Pharmacists and Pharmacies › Section 1369.610. Waiver Prohibited

Sec. 1369.610.  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.
Redesignated from Insurance Code, Section 1369.560 by Acts 2023, 88th Leg., R.S., Ch. 768 (H.B. 4595), Sec. 24.001(27), eff. September 1, 2023.
2023 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 N. Coverage of Prescription Drugs for Autoimmune Diseases and Certain Blood Disorders › Section 1369.651. Definition

Sec. 1369.651.  DEFINITION.  In this subchapter, "prescription drug" has the meaning assigned by Section 551.003, Occupations Code.
Added by Acts 2023, 88th Leg., R.S., Ch. 669 (H.B. 755), Sec. 1, eff. September 1, 2023.
2023 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 N. Coverage of Prescription Drugs for Autoimmune Diseases and Certain Blood Disorders › Section 1369.652. Applicability of Subchapter

Sec. 1369.652.  APPLICABILITY OF SUBCHAPTER.  (a)  This subchapter applies only to a health benefit plan that provides benefits for medical, surgical, or prescription drug 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 issued 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)  a basic coverage plan under Chapter 1551;
(4)  a basic plan under Chapter 1575;
(5)  a primary care coverage plan under Chapter 1579;
(6)  a plan providing basic coverage under Chapter 1601;
(7)  group health coverage made available by a school district in accordance with Section 22.004, Education Code; and
(8)  a self-funded health benefit plan sponsored by a professional employer organization under Chapter 91, Labor Code.
(c)  This subchapter 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.
Added by Acts 2023, 88th Leg., R.S., Ch. 669 (H.B. 755), Sec. 1, eff. September 1, 2023.
2023 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 N. Coverage of Prescription Drugs for Autoimmune Diseases and Certain Blood Disorders › Section 1369.653. Exceptions

Sec. 1369.653.  EXCEPTIONS.  (a)  This subchapter does not apply to:
(1)  a plan that provides coverage:
(A)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury; or
(B)  only for hospital expenses;
(2)  the state Medicaid program, including the Medicaid managed care program operated under Chapter 533, Government Code; or
(3)  the child health plan program under Chapter 62, Health and Safety Code.
(b)  This subchapter does not apply to an individual health benefit plan issued on or before March 23, 2010, that has not had any significant changes since that date that reduce benefits or increase costs to the individual.
Added by Acts 2023, 88th Leg., R.S., Ch. 669 (H.B. 755), Sec. 1, eff. September 1, 2023.
2023 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 N. Coverage of Prescription Drugs for Autoimmune Diseases and Certain Blood Disorders › Section 1369.654. Prohibition on Multiple Prior Authorizations

Sec. 1369.654.  PROHIBITION ON MULTIPLE PRIOR AUTHORIZATIONS.  (a)  A health benefit plan issuer that provides prescription drug benefits may not require an enrollee to receive more than one prior authorization annually of the prescription drug benefit for a prescription drug prescribed to treat an autoimmune disease, hemophilia, or Von Willebrand disease.
(b)  This section does not apply to:
(1)  opioids, benzodiazepines, barbiturates, or carisoprodol;
(2)  prescription drugs that have a typical treatment period of less than 12 months;
(3)  drugs that:
(A)  have a boxed warning assigned by the United States Food and Drug Administration for use; and
(B)  must have specific provider assessment; or
(4)  the use of a drug approved for use by the United States Food and Drug Administration in a manner other than the approved use.
Added by Acts 2023, 88th Leg., R.S., Ch. 669 (H.B. 755), Sec. 1, eff. September 1, 2023.
2023 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 Q. Clinician-Administered Drugs › Section 1369.761. Definitions

Sec. 1369.761.  DEFINITIONS.  In this subchapter:
(1)  "Administer" means to directly apply a drug to the body of a patient by injection, inhalation, ingestion, or any other means.
(2)  "Clinician-administered drug" means an outpatient prescription drug other than a vaccine that:
(A)  cannot reasonably be:
(i)  self-administered by the patient to whom the drug is prescribed; or
(ii)  administered by an individual assisting the patient with the self-administration; and
(B)  is typically administered:
(i)  by a physician or other health care provider authorized under the laws of this state to administer the drug, including when acting under a physician's delegation and supervision; and
(ii)  in a physician's office.
(3)  "Health care provider" means an individual who is licensed, certified, or otherwise authorized to provide health care services in this state.
(4)  "Physician" means an individual licensed to practice medicine in this state.
Added by Acts 2023, 88th Leg., R.S., Ch. 417 (H.B. 1647), Sec. 1, eff. September 1, 2023.
2023 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 Q. Clinician-Administered Drugs › Section 1369.762. Applicability of Subchapter

Sec. 1369.762.  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)  group health coverage made available by a school district in accordance with Section 22.004, Education Code;
(4)  a regional or local health care program operating under Section 75.104, Health and Safety Code; and
(5)  a self-funded health benefit plan sponsored by a professional employer organization under Chapter 91, Labor Code.
Added by Acts 2023, 88th Leg., R.S., Ch. 417 (H.B. 1647), Sec. 1, eff. September 1, 2023.
2023 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 Q. Clinician-Administered Drugs › Section 1369.763. Exceptions to Applicability of Subchapter

Sec. 1369.763.  EXCEPTIONS TO APPLICABILITY OF SUBCHAPTER.  (a)  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 under Chapter 533, Government Code;
(2)  the child health plan program under Chapter 62, Health and Safety Code;
(3)  the TRICARE military health system; or
(4)  a workers' compensation insurance policy or other form of providing medical benefits under Title 5, Labor Code.
(b)  This subchapter does not apply to a prescription drug administered in a hospital, hospital facility-based practice setting, or hospital outpatient infusion center.
Added by Acts 2023, 88th Leg., R.S., Ch. 417 (H.B. 1647), Sec. 1, eff. September 1, 2023.
2023 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 Q. Clinician-Administered Drugs › Section 1369.764. Certain Limitations on Coverage of Clinician-Administered Drugs Prohibited

Sec. 1369.764.  CERTAIN LIMITATIONS ON COVERAGE OF CLINICIAN-ADMINISTERED DRUGS PROHIBITED.  (a)  Subject to Subsection (b), a health benefit plan issuer may not, for an enrollee with a chronic, complex, rare, or life-threatening medical condition:
(1)  require clinician-administered drugs to be dispensed only by certain pharmacies or only by pharmacies participating in the health benefit plan issuer's network;
(2)  if a clinician-administered drug is otherwise covered, limit or exclude coverage for such drugs based on the enrollee's choice of pharmacy or because the drug was not dispensed by a pharmacy that participates in the health benefit plan issuer's network;
(3)  require a physician or health care provider participating in the health benefit plan issuer's network to bill for or be reimbursed for the delivery and administration of clinician-administered drugs under the pharmacy benefit instead of the medical benefit without:
(A)  informed written consent of the patient; and
(B)  a written attestation by the patient's physician or health care provider that a delay in the drug's administration will not place the patient at an increased health risk; or
(4)  require that an enrollee pay an additional fee, higher copay, higher coinsurance, second copay, second coinsurance, or any other price increase for clinician-administered drugs based on the enrollee's choice of pharmacy or because the drug was not dispensed by a pharmacy that participates in the health benefit plan issuer's network.
(b)  Subsection (a) applies only if the patient's physician or health care provider determines that:
(1)  a delay of care would make disease progression probable; or
(2)  the use of a pharmacy within the health benefit plan issuer's network would:
(A)  make death or patient harm probable;
(B)  potentially cause a barrier to the patient's adherence to or compliance with the patient's plan of care; or
(C)  because of the timeliness of the delivery or dosage requirements, necessitate delivery by a different pharmacy.
(c)  Nothing in this section may be construed to:
(1)  authorize a person to administer a drug when otherwise prohibited under the laws of this state or federal law; or
(2)  modify drug administration requirements under the laws of this state, including any requirements related to delegation and supervision of drug administration.
Added by Acts 2023, 88th Leg., R.S., Ch. 417 (H.B. 1647), Sec. 1, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1370 - Certain Tests for Detection of Human Papillomavirus, Ovarian Cancer, and Cervical Cancer › Section 1370.001. Applicability of Chapter

Sec. 1370.001.  APPLICABILITY OF CHAPTER.  (a)  This chapter 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, an individual or group evidence of coverage, or a 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 health maintenance organization operating under Chapter 843;
(6)  a reciprocal exchange operating under Chapter 942;
(7)  a Lloyd's plan operating under Chapter 941;
(8)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844; or
(9)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846.
(b)  This chapter applies to a small employer health benefit plan written under Chapter 1501.
Added by Acts 2005, 79th Leg., Ch. 577 (H.B. 1485), Sec. 1, eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1370 - Certain Tests for Detection of Human Papillomavirus, Ovarian Cancer, and Cervical Cancer › Section 1370.002. Exceptions

Sec. 1370.002.  EXCEPTIONS.  (a) 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 cancer treatment or similar services;
(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 1370.001.
(b)  To the extent that providing coverage for ovarian cancer screening under this chapter would otherwise require this state to make a payment under 42 U.S.C. Section 18031(d)(3)(B)(ii), a qualified health plan, as defined by 45 C.F.R. Section 155.20, is not required to provide a benefit for the ovarian cancer screening under this chapter that exceeds the specified essential health benefits required under 42 U.S.C. Section 18022(b).
Added by Acts 2005, 79th Leg., Ch. 577 (H.B. 1485), Sec. 1, eff. September 1, 2005.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 176 (H.B. 2813), Sec. 2, eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1370 - Certain Tests for Detection of Human Papillomavirus, Ovarian Cancer, and Cervical Cancer › Section 1370.003. Coverage Required

Sec. 1370.003.  COVERAGE REQUIRED.  (a)  A health benefit plan that provides coverage for diagnostic medical procedures must provide to each woman 18 years of age or older enrolled in the plan coverage for expenses for an annual medically recognized diagnostic examination for the early detection of ovarian cancer and cervical cancer.
(b)  Coverage required under this section includes at a minimum:
(1)  a CA 125 blood test;
(2)  a conventional Pap smear screening or a screening using liquid-based cytology methods, as approved by the United States Food and Drug Administration, alone or in combination with a test approved by the United States Food and Drug Administration for the detection of the human papillomavirus; and
(3)  any other test or screening approved by the United States Food and Drug Administration for the detection of ovarian cancer.
(c)  A screening test required under this section must be performed in accordance with the guidelines adopted by:
(1)  the American College of Obstetricians and Gynecologists; or
(2)  another similar national organization of medical professionals recognized by the commissioner.
Added by Acts 2005, 79th Leg., Ch. 577 (H.B. 1485), Sec. 1, eff. September 1, 2005.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 176 (H.B. 2813), Sec. 3, eff. September 1, 2015.
Acts 2021, 87th Leg., R.S., Ch. 312 (H.B. 428), Sec. 1, eff. September 1, 2021.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1370 - Certain Tests for Detection of Human Papillomavirus, Ovarian Cancer, and Cervical Cancer › Section 1370.004. Notice of Coverage

Sec. 1370.004.  NOTICE OF COVERAGE.  (a)  A health benefit plan issuer shall provide to each woman 18 years of age or older enrolled in the plan written notice of the coverage required under this chapter.
(b)  The notice must be provided in accordance with rules adopted by the commissioner.
Added by Acts 2005, 79th Leg., Ch. 577 (H.B. 1485), Sec. 1, eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1371 - Coverage for Certain Prosthetic Devices, Orthotic Devices, and Related Services › Section 1371.001. Definitions

Sec. 1371.001.  DEFINITIONS.  In this chapter:
(1)  "Enrollee" means an individual entitled to coverage under a health benefit plan.
(2)  "Orthotic device" means a custom-fitted or custom-fabricated medical device that is applied to a part of the human body to correct a deformity, improve function, or relieve symptoms of a disease.
(3)  "Prosthetic device" means an artificial device designed to replace, wholly or partly, an arm or leg.
Added by Acts 2009, 81st Leg., R.S., Ch. 30 (H.B. 806), Sec. 1, eff. September 1, 2009.