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 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.
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 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.
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 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.
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 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.
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 B. -2. Disclosure of Certain Prescription Drug Information Specified by Drug Formulary › Section 1369.091. Definitions

Sec. 1369.091.  DEFINITIONS.  In this subchapter:
(1)  "Cost-sharing information" means the actual out-of-pocket amount an enrollee is required to pay a dispensing pharmacy or prescribing provider for a prescription drug under the enrollee's health benefit plan.
(2)  "Drug formulary," "enrollee," and "prescription drug" have the meanings assigned by Section 1369.051.
(3)  "Standard API" means an application interface that meets the requirements of an applicable American National Standards Institute (ANSI) accredited standard to conform to standards adopted under 45 C.F.R. Section 170.215.
Added by Acts 2023, 88th Leg., R.S., Ch. 272 (S.B. 622), 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 B. -2. Disclosure of Certain Prescription Drug Information Specified by Drug Formulary › Section 1369.092. Applicability of Subchapter

Sec. 1369.092.  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)  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)  alternative health benefit coverage offered by a subsidiary of the Texas Mutual Insurance Company under Subchapter M, Chapter 2054;
(8)  a regional or local health care program operated under Section 75.104, Health and Safety Code; and
(9)  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. 272 (S.B. 622), 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 B. -2. Disclosure of Certain Prescription Drug Information Specified by Drug Formulary › Section 1369.093. Exceptions to Applicability of Subchapter

Sec. 1369.093.  EXCEPTIONS TO APPLICABILITY OF SUBCHAPTER.  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; or
(4)  a workers' compensation insurance policy or other form of providing medical benefits under Title 5, Labor Code.
Added by Acts 2023, 88th Leg., R.S., Ch. 272 (S.B. 622), 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 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.
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 C. Coverage of Prescription Contraceptive Drugs and Devices and Related Services › Section 1369.102. Applicability of Subchapter

Sec. 1369.102.  APPLICABILITY OF SUBCHAPTER.  Except as otherwise provided by this subchapter, this subchapter applies only to a health benefit plan, including a small employer health benefit plan written under Chapter 1501, that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage or similar coverage document that is offered by:
(1)  an insurance company;
(2)  a group hospital service corporation operating under Chapter 842;
(3)  a fraternal benefit society operating under Chapter 885;
(4)  a stipulated premium company operating under Chapter 884;
(5)  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 2023, 88th Leg., R.S., Ch. 395 (H.B. 916), 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 C. Coverage of Prescription Contraceptive Drugs and Devices and Related Services › Section 1369.103. Exception

Sec. 1369.103.  EXCEPTION.  This subchapter does not apply to:
(1)  a health benefit plan that provides coverage only:
(A)  for a specified disease or for another limited benefit other than for cancer;
(B)  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)  for dental or vision care;  or
(G)  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;  or
(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 1369.102.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
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 C. Coverage of Prescription Contraceptive Drugs and Devices and Related Services › Section 1369.1031. Certain Coverage Required

Sec. 1369.1031.  CERTAIN COVERAGE REQUIRED.  (a)  This section applies to a health benefit plan described by Section 1369.102.
(b)  Notwithstanding any other law, this section applies to:
(1)  a standard health benefit plan issued under Chapter 1507;
(2)  a basic coverage plan under Chapter 1551;
(3)  a basic plan under Chapter 1575;
(4)  a primary care coverage plan under Chapter 1579;
(5)  a plan providing basic coverage under Chapter 1601;
(6)  group health coverage made available by a school district in accordance with Section 22.004, Education Code; and
(7)  the state Medicaid program, including the Medicaid managed care program operated under Chapter 533, Government Code.
(c)  A health benefit plan that provides benefits for a prescription contraceptive drug must provide for an enrollee to obtain up to:
(1)  a three-month supply of the covered prescription contraceptive drug at one time the first time the enrollee obtains the drug; and
(2)  a 12-month supply of the covered prescription contraceptive drug at one time each subsequent time the enrollee obtains the same drug, regardless of whether the enrollee was enrolled in the health benefit plan the first time the enrollee obtained the drug.
(d)  An enrollee may obtain only one 12-month supply of a covered prescription contraceptive drug during each 12-month period.
Added by Acts 2023, 88th Leg., R.S., Ch. 395 (H.B. 916), Sec. 2, 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 C. Coverage of Prescription Contraceptive Drugs and Devices and Related Services › Section 1369.104. Exclusion or Limitation Prohibited

Sec. 1369.104.  EXCLUSION OR LIMITATION PROHIBITED.  (a)  A health benefit plan that provides benefits for prescription drugs or devices may not exclude or limit benefits to enrollees for:
(1)  a prescription contraceptive drug or device approved by the United States Food and Drug Administration;  or
(2)  an outpatient contraceptive service.
(b)  This section does not prohibit a limitation that applies to all prescription drugs or devices or all services for which benefits are provided under a health benefit plan.
(c)  This section does not require a health benefit plan to cover abortifacients or any other drug or device that terminates a pregnancy.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
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 C. Coverage of Prescription Contraceptive Drugs and Devices and Related Services › Section 1369.105. Certain Cost-Sharing Provisions Prohibited

Sec. 1369.105.  CERTAIN COST-SHARING PROVISIONS PROHIBITED.  (a)  A health benefit plan may not impose a deductible, copayment, coinsurance, or other cost-sharing provision applicable to benefits for prescription contraceptive drugs or devices unless the amount of the required cost-sharing is the same as or less than the amount of the required cost-sharing applicable to benefits for other prescription drugs or devices under the plan.
(b)  A health benefit plan may not impose a deductible, copayment, coinsurance, or other cost-sharing provision applicable to benefits for outpatient contraceptive services unless the amount of the required cost-sharing is the same as or less than the amount of the required cost-sharing applicable to benefits for other outpatient services under the plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
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 C. Coverage of Prescription Contraceptive Drugs and Devices and Related Services › Section 1369.106. Certain Waiting Periods Prohibited

Sec. 1369.106.  CERTAIN WAITING PERIODS PROHIBITED.  (a)  A health benefit plan may not impose a waiting period applicable to benefits for prescription contraceptive drugs or devices unless the waiting period is the same as or shorter than any waiting period applicable to benefits for other prescription drugs or devices under the plan.
(b)  A health benefit plan may not impose a waiting period applicable to benefits for outpatient contraceptive services unless the waiting period is the same as or shorter than any waiting period applicable to benefits for other outpatient services under the plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
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 C. Coverage of Prescription Contraceptive Drugs and Devices and Related Services › Section 1369.107. Prohibited Conduct

Sec. 1369.107.  PROHIBITED CONDUCT.  A health benefit plan issuer may not:
(1)  solely because of the applicant's or enrollee's use or potential use of a prescription contraceptive drug or device or an outpatient contraceptive service, deny:
(A)  the eligibility of an applicant to enroll in the plan;
(B)  the continued eligibility of an enrollee for coverage under the plan;  or
(C)  the eligibility of an enrollee to renew coverage under the plan;
(2)  provide a monetary incentive to an applicant for enrollment or an enrollee to induce the applicant or enrollee to accept coverage that does not satisfy the requirements of this subchapter;  or
(3)  reduce or limit a payment to a health care professional, or otherwise penalize the professional, because the professional prescribes a contraceptive drug or device or provides an outpatient contraceptive service.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
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 C. Coverage of Prescription Contraceptive Drugs and Devices and Related Services › Section 1369.108. Exemption for Entities Associated With Religious Organization

Sec. 1369.108.  EXEMPTION FOR ENTITIES ASSOCIATED WITH RELIGIOUS ORGANIZATION.  (a)  This subchapter does not require a health benefit plan that is issued by an entity associated with a religious organization or any physician or health care provider providing medical or health care services under the plan to offer, recommend, offer advice concerning, pay for, provide, assist in, perform, arrange, or participate in providing or performing a medical or health care service that violates the religious convictions of the organization, unless the prescription contraceptive coverage is necessary to preserve the life or health of the enrollee.
(b)  An issuer of a health benefit plan that excludes or limits coverage for medical or health care services under this section shall state the exclusion or limitation in:
(1)  the plan's coverage document;
(2)  the plan's statement of benefits;
(3)  plan brochures;  and
(4)  other informational materials for the plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
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 C. Coverage of Prescription Contraceptive Drugs and Devices and Related Services › Section 1369.109. Enforcement

Sec. 1369.109.  ENFORCEMENT.  A health benefit plan issuer that violates this subchapter is subject to the enforcement provisions of Subtitle B, Title 2.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
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 D. Pharmacy Benefit Cards › Section 1369.151. Applicability of Subchapter

Sec. 1369.151.  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 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.
(b)  Notwithstanding any other law, this subchapter applies to coverage under:
(1)  the basic coverage plan under Chapter 1551;
(2)  the basic plan under Chapter 1575;
(3)  the primary care coverage plan under Chapter 1579;
(4)  the basic coverage plan under Chapter 1601;
(5)  the child health plan program under Chapter 62, Health and Safety Code; and
(6)  the medical assistance program under Chapter 32, Human Resources Code.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2009, 81st Leg., R.S., Ch. 1117 (H.B. 1138), Sec. 1, eff. September 1, 2009.
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 D. Pharmacy Benefit Cards › Section 1369.152. Exception

Sec. 1369.152.  EXCEPTION.  This subchapter does not apply to:
(1)  a health benefit plan that provides coverage:
(A)  only for a specified disease or for another limited 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 small employer health benefit plan written under Chapter 1501;
(3)  a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
(4)  a workers' compensation insurance policy;
(5)  medical payment insurance coverage provided under a motor vehicle insurance policy;  or
(6)  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 1369.151.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
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 D. Pharmacy Benefit Cards › Section 1369.153. Information Required on Identification Card

Sec. 1369.153.  INFORMATION REQUIRED ON IDENTIFICATION CARD.  (a)  An issuer of a health benefit plan that provides pharmacy benefits to enrollees shall include on the front of the identification card of each enrollee:
(1)  the name of the entity administering the pharmacy benefits if the entity is different from the health benefit plan issuer;
(2)  the group number applicable to the enrollee;
(3)  the identification number of the enrollee, which may not be the enrollee's social security number;
(4)  the bank identification number necessary for electronic billing;
(5)  the effective date of the coverage evidenced by the card; and
(6)  copayment information for generic and brand-name prescription drugs.
(b)  In addition to the information required under Subsection (a), the issuer of a health benefit plan shall include on the identification card of each enrollee:
(1)  the logo of the entity administering the pharmacy benefits if the entity is different from the health benefit plan issuer; and
(2)  a telephone number for contacting an appropriate person to obtain information relating to the pharmacy benefits provided under the plan.
(c)  In addition to complying with Subsections (a) and (b), an issuer of a health benefit plan may provide the information required under Subsections (a) and (b) in electronically readable form on the back of the identification card.
(d)  This section does not require a health benefit plan issuer that administers its own pharmacy benefits to issue an identification card separate from any identification card issued to an enrollee to evidence coverage under the plan if the identification card issued to evidence coverage contains the information required by Subsections (a) and (b).
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2009, 81st Leg., R.S., Ch. 1117 (H.B. 1138), Sec. 2, eff. September 1, 2009.
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 D. Pharmacy Benefit Cards › Section 1369.154. Rules

Sec. 1369.154.  RULES.  (a)  The commissioner shall adopt rules as necessary to implement this subchapter.
(b)  Rules adopted by the commissioner must be consistent with national standards established by the Workgroup for Electronic Data Interchange or by other similar organizations recognized by the commissioner.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2009, 81st Leg., R.S., Ch. 1117 (H.B. 1138), Sec. 3, eff. September 1, 2009.
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 E. Coverage for Orally Administered Anticancer Medications › Section 1369.201. Definitions

Sec. 1369.201.  DEFINITIONS.  In this subchapter:
(1)  "Health benefit exchange" means an American Health Benefit Exchange administered by the federal government or created pursuant to Section 1311(b), Patient Protection and Affordable Care Act (42 U.S.C. Section 18031).
(2)  "Qualified health plan" has the meaning assigned by Section 1301(a), Patient Protection and Affordable Care Act (42 U.S.C. Section 18021).
Added by Acts 2011, 82nd Leg., R.S., Ch. 105 (H.B. 438), Sec. 1, eff. September 1, 2011.
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 E. Coverage for Orally Administered Anticancer Medications › Section 1369.202. Applicability of Subchapter

Sec. 1369.202.  APPLICABILITY OF SUBCHAPTER.  This subchapter applies only to a health benefit plan, including a small employer health benefit plan written under Chapter 1501 or coverage provided by a health group cooperative under Subchapter B of that chapter, that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage or similar coverage document that is offered by:
(1)  an insurance company;
(2)  a group hospital service corporation operating under Chapter 842;
(3)  a fraternal benefit society operating under Chapter 885;
(4)  a stipulated premium company operating under Chapter 884;
(5)  an exchange operating under Chapter 942;
(6)  a Lloyd's plan operating under Chapter 941;
(7)  a health maintenance organization operating under Chapter 843; or
(8)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844.
Added by Acts 2011, 82nd Leg., R.S., Ch. 105 (H.B. 438), Sec. 1, eff. September 1, 2011.
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 E. Coverage for Orally Administered Anticancer Medications › Section 1369.203. Exception

Sec. 1369.203.  EXCEPTION.  (a)  This subchapter does not apply to:
(1)  a plan that provides coverage:
(A)  only for fixed indemnity benefits for a specified disease or diseases;
(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;
(7)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846; or
(8)  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 1369.201.
(b)  This subchapter does not apply to a qualified health plan offered through a health benefit exchange.
Added by Acts 2011, 82nd Leg., R.S., Ch. 105 (H.B. 438), Sec. 1, eff. September 1, 2011.
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 E. Coverage for Orally Administered Anticancer Medications › Section 1369.204. Required Coverage for Orally Administered Anticancer Medications

Sec. 1369.204.  REQUIRED COVERAGE FOR ORALLY ADMINISTERED ANTICANCER MEDICATIONS.  (a)  A health benefit plan that provides coverage for cancer treatment must provide coverage for a prescribed, orally administered anticancer medication that is used to kill or slow the growth of cancerous cells on a basis no less favorable than intravenously administered or injected cancer medications that are covered as medical benefits by the plan.
(b)  This section does not prohibit a health benefit plan from requiring prior authorization for an orally administered anticancer medication.  If an orally administered anticancer medication is authorized, the cost to the covered individual may not exceed the coinsurance or copayment that would be applied to a chemotherapy or other cancer treatment visit.
(c)  A health benefit plan issuer may not reclassify anticancer medications or increase a coinsurance, copayment, deductible, or other out-of-pocket expense imposed on anticancer medications to achieve compliance with this section. Any plan change that otherwise increases an out-of-pocket expense applied to anticancer medications must also be applied to the majority of comparable medical or pharmaceutical benefits under the plan.
(d)  This section does not prohibit a health benefit plan issuer from increasing cost-sharing for all benefits, including anticancer treatments.
Added by Acts 2011, 82nd Leg., R.S., Ch. 105 (H.B. 438), Sec. 1, eff. September 1, 2011.
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 E. -1. Coverage of Prescription Drugs for Stage-Four Advanced, Metastatic Cancer › Section 1369.211. Definitions

Sec. 1369.211.  DEFINITIONS.  In this subchapter:
(1)  "Associated conditions" means the symptoms or side effects associated with stage-four advanced, metastatic cancer or its treatment and which, in the judgment of the health care practitioner, further jeopardize the health of a patient if left untreated.
(2)  "Stage-four advanced, metastatic cancer" means cancer that has spread from the primary or original site of the cancer to nearby tissues, lymph nodes, or other areas or parts of the body.
Added by Acts 2019, 86th Leg., R.S., Ch. 1350 (H.B. 1584), Sec. 1, 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 E. -1. Coverage of Prescription Drugs for Stage-Four Advanced, Metastatic Cancer › Section 1369.213. Prohibited Conduct

Sec. 1369.213.  PROHIBITED CONDUCT.  (a)  A health benefit plan that provides coverage for stage-four advanced, metastatic cancer and associated conditions may not require, before the health benefit plan provides coverage of a prescription drug approved by the United States Food and Drug Administration, that the enrollee:
(1)  fail to successfully respond to a different drug; or
(2)  prove a history of failure of a different drug.
(b)  This section applies only to a drug the use of which is:
(1)  consistent with best practices for the treatment of stage-four advanced, metastatic cancer or an associated condition;
(2)  supported by peer-reviewed, evidence-based literature; and
(3)  approved by the United States Food and Drug Administration.
Added by Acts 2019, 86th Leg., R.S., Ch. 1350 (H.B. 1584), Sec. 1, 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 F. Audits of Pharmacists and Pharmacies › Section 1369.251. Definitions

Sec. 1369.251.  DEFINITIONS.  In this subchapter:
(1)  "Desk audit" means an audit conducted by a health benefit plan issuer or pharmacy benefit manager at a location other than the location of the pharmacist or pharmacy.  The term includes an audit performed at the offices of the plan issuer or pharmacy benefit manager during which the pharmacist or pharmacy provides requested documents for review by hard copy or by microfiche, disk, or other electronic media.  The term does not include a review conducted not later than the third business day after the date a claim is adjudicated provided recoupment is not demanded.
(2)  "Extrapolation" means a mathematical process or technique used by a health benefit plan issuer or pharmacy benefit manager that administers pharmacy claims for a health benefit plan issuer in the audit of a pharmacy or pharmacist to estimate audit results or findings for a larger batch or group of claims not reviewed by the plan issuer or pharmacy benefit manager.
(3)  "Health benefit plan" means a plan that provides benefits for medical, surgical, or other treatment expenses incurred as a result of a health condition, a mental health condition, an accident, sickness, or substance abuse, including:
(A)  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:
(i)  an insurance company;
(ii)  a group hospital service corporation operating under Chapter 842;
(iii)  a health maintenance organization operating under Chapter 843;
(iv)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844;
(v)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846;
(vi)  a stipulated premium company operating under Chapter 884;
(vii)  a fraternal benefit society operating under Chapter 885;
(viii)  a Lloyd's plan operating under Chapter 941; or
(ix)  an exchange operating under Chapter 942;
(B)  a small employer health benefit plan written under Chapter 1501; or
(C)  a health benefit plan issued under Chapter 1551, 1575, 1579, or 1601.
(4)  "On-site audit" means an audit that is conducted at:
(A)  the location of the pharmacist or pharmacy; or
(B)  another location at which the records under review are stored.
(5)  "Pharmacy benefit manager" has the meaning assigned by Section 4151.151.
Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.
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 F. Audits of Pharmacists and Pharmacies › Section 1369.252. Exceptions to Applicability of Subchapter

Sec. 1369.252.   EXCEPTIONS TO APPLICABILITY OF SUBCHAPTER.  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;
(2)  the federal Medicare program;
(3)  the state child health plan or health benefits plan for children under Chapter 62 or 63, Health and Safety Code;
(4)  the TRICARE military health system;
(5)  a workers' compensation insurance policy or other form of providing medical benefits under Title 5, Labor Code; or
(6)  a self-funded health benefit plan as defined by the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.).
Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.
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 F. Audits of Pharmacists and Pharmacies › Section 1369.253. Conflict With Other Laws

Sec. 1369.253.  CONFLICT WITH OTHER LAWS.  If there is a conflict between this subchapter and a provision of Chapter 843 or 1301 related to a pharmacy benefit manager, this subchapter prevails.
Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.
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 F. Audits of Pharmacists and Pharmacies › Section 1369.255. Completion of Audit

Sec. 1369.255.  COMPLETION OF AUDIT.  An audit of a claim under Section 1369.254 must be completed on or before the one-year anniversary of the date the claim is received by the health benefit plan issuer or pharmacy benefit manager.
Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.
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 F. Audits of Pharmacists and Pharmacies › Section 1369.256. Audit Requiring Professional Judgment

Sec. 1369.256.  AUDIT REQUIRING PROFESSIONAL JUDGMENT.  A health benefit plan issuer or pharmacy benefit manager that conducts an on-site audit or a desk audit involving a pharmacist's clinical or professional judgment must conduct the audit in consultation with a licensed pharmacist.
Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.
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 F. Audits of Pharmacists and Pharmacies › Section 1369.257. Access to Pharmacy Area

Sec. 1369.257.  ACCESS TO PHARMACY AREA.  A health benefit plan issuer or pharmacy benefit manager that conducts an on-site audit may not enter the pharmacy area unless escorted by an individual authorized by the pharmacist or pharmacy.
Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.
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 F. Audits of Pharmacists and Pharmacies › Section 1369.258. Validation Using Certain Records Authorized

Sec. 1369.258.  VALIDATION USING CERTAIN RECORDS AUTHORIZED.  A pharmacist or pharmacy that is being audited may:
(1)  validate a prescription, refill of a prescription, or change in a prescription with a prescription that complies with applicable federal laws and regulations and state laws and rules adopted under Section 554.051, Occupations Code; and
(2)  validate the delivery of a prescription with a written record of a hospital, physician, or other authorized practitioner of the healing arts.
Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.
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 F. Audits of Pharmacists and Pharmacies › Section 1369.2581. Audit Discrepancies; Wholesale Invoices

Sec. 1369.2581.  AUDIT DISCREPANCIES; WHOLESALE INVOICES.  (a)  A health benefit plan issuer or pharmacy benefit manager that audits wholesale invoices during an audit of a pharmacist or pharmacy may not audit the pharmacy claims of another health benefit plan or pharmacy benefit manager.
(b)  A health benefit plan issuer or pharmacy benefit manager shall reverse a finding of a discrepancy if:
(1)  the National Drug Code for the dispensed drug is in a quantity that is a subunit or multiple of the drug purchased by the pharmacist or pharmacy as supported by a wholesale invoice;
(2)  the pharmacist or pharmacy dispensed the correct quantity of the drug according to the prescription; and
(3)  the drug dispensed by the pharmacist or pharmacy shares all but the last two digits of the National Drug Code of the drug reflected on the supplier invoice.
(c)  A health benefit plan issuer or pharmacy benefit manager must accept as evidence to support the validity of a pharmacy claim related to a dispensed drug:
(1)  subject to validation, including validation by pharmacy purchase order and payment of a supplier invoice, copies of supplier invoices in the pharmacist's or pharmacy's possession, including:
(A)  supplier invoices issued before the date the drug was dispensed and not earlier than 60 days before the first day of the audit period; and
(B)  invoices and any supporting documents from any supplier authorized by federal or state law to transfer ownership of the drug acquired by the pharmacist or pharmacy; and
(2)  reports required by any state board or agency.
(d)  A health benefit plan issuer or pharmacy benefit manager must provide, not later than the fifth business day after the date of a request by the pharmacist or pharmacy, any supporting documents the pharmacist's or pharmacy's suppliers provided to the health benefit plan issuer or pharmacy benefit manager.
Added by Acts 2019, 86th Leg., R.S., Ch. 481 (H.B. 1455), Sec. 1, eff. September 1, 2019.