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 1367 - Coverage of Children › Subchapter E. Developmental Delays › Section 1367.207. Rules

Sec. 1367.207.  RULES.  The commissioner may adopt rules necessary to implement this subchapter.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.040(a), 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 1367 - Coverage of Children › Subchapter F. Hearing AIDS and Cochlear Implants › Section 1367.251. Applicability of Subchapter

Sec. 1367.251.  APPLICABILITY OF SUBCHAPTER.  (a)  This subchapter applies only to a health benefit plan, including a small employer health benefit plan written under Chapter 1501 or coverage provided through 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 Lloyd's plan operating under Chapter 941;
(5)  a stipulated premium insurance company operating under Chapter 884;
(6)  a reciprocal exchange operating under Chapter 942;
(7)  a health maintenance organization operating under Chapter 843;
(8)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846; or
(9)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844.
(b)  This subchapter applies to coverage under a group health benefit plan described by Subsection (a) provided to a resident of this state, regardless of whether the group policy, agreement, or contract is delivered, issued for delivery, or renewed within or outside this state.
(c)  This subchapter applies to a self-funded health benefit plan sponsored by a professional employer organization under Chapter 91, Labor Code.
(d)  Notwithstanding Section 22.409, Business Organizations Code, or any other law, this subchapter applies to health benefits provided by or through a church benefits board under Subchapter I, Chapter 22, Business Organizations Code.
(e)  Notwithstanding Section 75.104, Health and Safety Code, or any other law, this subchapter applies to a regional or local health care program operated under that section.
(f)  Notwithstanding any other law, a standard health benefit plan provided under Chapter 1507 must provide the coverage required by this subchapter.
(g)  Notwithstanding any provision in Chapter 1551, 1575, 1579, or 1601 or any other law, this subchapter applies to:
(1)  a basic coverage plan under Chapter 1551;
(2)  a basic plan under Chapter 1575;
(3)  a primary care coverage plan under Chapter 1579; and
(4)  basic coverage under Chapter 1601.
Added by Acts 2017, 85th Leg., R.S., Ch. 979 (H.B. 490), 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 1367 - Coverage of Children › Subchapter F. Hearing AIDS and Cochlear Implants › Section 1367.252. Exception

Text of section effective until April 01, 2025
Sec. 1367.252.  EXCEPTION.  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;
(B)  as a supplement to a liability insurance policy;
(C)  for credit insurance;
(D)  only for dental or vision care;
(E)  only for hospital expenses; 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 a motor vehicle insurance policy;
(5)  a long-term care 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 1367.251; or
(6)  the state Medicaid program, including the Medicaid managed care program operated under Chapter 533, Government Code.
Added by Acts 2017, 85th Leg., R.S., Ch. 979 (H.B. 490), Sec. 1, eff. September 1, 2017.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.124, 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 1367 - Coverage of Children › Subchapter F. Hearing AIDS and Cochlear Implants › Section 1367.252. Exception

Text of section effective on April 01, 2025
Sec. 1367.252.  EXCEPTION.  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;
(B)  as a supplement to a liability insurance policy;
(C)  for credit insurance;
(D)  only for dental or vision care;
(E)  only for hospital expenses; 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 a motor vehicle insurance policy;
(5)  a long-term care 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 1367.251; or
(6)  the state Medicaid program, including the Medicaid managed care program operated under Chapters 540 and 540A, Government Code.
Added by Acts 2017, 85th Leg., R.S., Ch. 979 (H.B. 490), Sec. 1, eff. September 1, 2017.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.124, 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 1367 - Coverage of Children › Subchapter F. Hearing AIDS and Cochlear Implants › Section 1367.253. Coverage Required

Sec. 1367.253.  COVERAGE REQUIRED.  (a) A health benefit plan must provide coverage for the cost of a medically necessary hearing aid or cochlear implant and related services and supplies for a covered individual who is 18 years of age or younger.
(b)  Coverage required under this section:
(1)  must include:
(A)  fitting and dispensing services and the provision of ear molds as necessary to maintain optimal fit of hearing aids;
(B)  any treatment related to hearing aids and cochlear implants, including coverage for habilitation and rehabilitation as necessary for educational gain; and
(C)  for a cochlear implant, an external speech processor and controller with necessary components replacement every three years; and
(2)  is limited to:
(A)  one hearing aid in each ear every three years; and
(B)  one cochlear implant in each ear with internal replacement as medically or audiologically necessary.
(c)  Except as provided by Subsections (b) and (d), coverage required under this section:
(1)  may not be less favorable than coverage for physical illness generally under the plan; and
(2)  must be subject to durational limits and coinsurance factors no less favorable than coverage provided for physical illness generally under the plan.
(d)  Coverage required under this section is subject to any provision that applies generally to coverage provided for durable medical equipment benefits under the plan, including a provision relating to deductibles, coinsurance, or prior authorization.
(e)  This section does not apply to a qualified health plan defined by 45 C.F.R. Section 155.20 if a determination is made under 45 C.F.R. Section 155.170 that:
(1)  this subchapter requires the plan to offer benefits in addition to the essential health benefits required under 42 U.S.C. Section 18022(b); and
(2)  this state must make payments to defray the cost of the additional benefits mandated by this subchapter.
Added by Acts 2017, 85th Leg., R.S., Ch. 979 (H.B. 490), 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 1368 - Availability of Chemical Dependency Coverage › Section 1368.001. Definitions

Sec. 1368.001.  DEFINITIONS.  In this chapter:
(1)  "Chemical dependency" means the abuse of, a psychological or physical dependence on, or an addiction to alcohol or a controlled substance.
(2)  "Chemical dependency treatment center" means a facility that provides a program for the treatment of chemical dependency under a written treatment plan approved and monitored by a physician and that is:
(A)  affiliated with a hospital under a contractual agreement with an established system for patient referral;
(B)  accredited as a chemical dependency treatment center by the Joint Commission on Accreditation of Healthcare Organizations;
(C)  licensed as a chemical dependency treatment program by the Texas Commission on Alcohol and Drug Abuse;  or
(D)  licensed, certified, or approved as a chemical dependency treatment program or center by another state agency.
(3)  "Controlled substance" means an abusable volatile chemical, as defined by Section 485.001, Health and Safety Code, or a substance designated as a controlled substance under Chapter 481, Health and Safety Code.
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 1368 - Availability of Chemical Dependency Coverage › Section 1368.002. Applicability of Chapter

Sec. 1368.002.  APPLICABILITY OF CHAPTER.  This chapter applies only to a group health benefit plan that provides hospital and medical coverage or services on an expense incurred, service, or prepaid basis, including a group insurance policy or contract or self-funded or self-insured plan or arrangement that is offered in this state by:
(1)  an insurer;
(2)  a group hospital service corporation operating under Chapter 842;
(3)  a health maintenance organization operating under Chapter 843;  or
(4)  an employer, trustee, or other self-funded or self-insured plan or arrangement.
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 1368 - Availability of Chemical Dependency Coverage › Section 1368.003. Exception

Sec. 1368.003.  EXCEPTION.  This chapter does not apply to:
(1)  an employer, trustee, or other self-funded or self-insured plan or arrangement with 250 or fewer employees or members;
(2)  an individual insurance policy;
(3)  an individual evidence of coverage issued by a health maintenance organization;
(4)  a health insurance policy that provides only:
(A)  cash indemnity for hospital or other confinement benefits;
(B)  supplemental or limited benefit coverage;
(C)  coverage for specified diseases or accidents;
(D)  disability income coverage;  or
(E)  any combination of those benefits or coverages;
(5)  a blanket insurance policy;
(6)  a short-term travel insurance policy;
(7)  an accident-only insurance policy;
(8)  a limited or specified disease insurance policy;
(9)  an individual conversion insurance policy or contract;
(10)  a policy or contract designed for issuance to a person eligible for Medicare coverage or other similar coverage under a state or federal government plan;  or
(11)  an evidence of coverage provided by a health maintenance organization if the plan holder is the subject of a collective bargaining agreement that was in effect on January 1, 1982, and that has not expired since that date.
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 1368 - Availability of Chemical Dependency Coverage › Section 1368.004. Coverage Required

Sec. 1368.004.  COVERAGE REQUIRED.  (a)  A group health benefit plan shall provide coverage for the necessary care and treatment of chemical dependency.
(b)  Coverage required under this section may be provided:
(1)  directly by the group health benefit plan issuer;  or
(2)  by another entity, including a single service health maintenance organization, under contract with the group health benefit plan issuer.
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 1368 - Availability of Chemical Dependency Coverage › Section 1368.005. Minimum Coverage Requirements

Sec. 1368.005.  MINIMUM COVERAGE REQUIREMENTS.  (a)  Except as provided by Subsection (b), coverage required under this chapter:
(1)  may not be less favorable than coverage provided for physical illness generally under the plan;  and
(2)  shall be subject to the same durational limits, dollar limits, deductibles, and coinsurance factors that apply to coverage provided for physical illness generally under the plan.
(b)  A group health benefit plan may set dollar or durational limits for coverage required under this chapter that are less favorable than for coverage provided for physical illness generally under the plan if those limits are sufficient to provide appropriate care and treatment under the guidelines and standards adopted under Section 1368.007.  If guidelines and standards adopted under Section 1368.007 are not in effect, the dollar and durational limits may not be less favorable than for physical illness generally.
(c)  This section does not require payment of a usual, customary, and reasonable rate for treatment of a covered individual if a health maintenance organization or preferred provider organization establishes a negotiated rate for the locality in which the covered individual customarily receives care.
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 1368 - Availability of Chemical Dependency Coverage › Section 1368.006. Limitation on Coverage

Sec. 1368.006.  LIMITATION ON COVERAGE.  (a)  In this section, "treatment series" means a planned, structured, and organized program to promote chemical-free status that:
(1)  may include different facilities or modalities;  and
(2)  is completed when the covered individual:
(A)  is, on medical advice, discharged from:
(i)  inpatient detoxification;
(ii)  inpatient rehabilitation or treatment;
(iii)  partial hospitalization or intensive outpatient treatment;  or
(iv)  a series of those levels of treatments without a lapse in treatment;  or
(B)  fails to materially comply with the treatment program for a period of 30 days.
(b)  Notwithstanding Section 1368.005, coverage required under this chapter is limited to a lifetime maximum of three separate treatment series for each covered individual.
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 1368 - Availability of Chemical Dependency Coverage › Section 1368.007. Treatment Standards

Sec. 1368.007.  TREATMENT STANDARDS.  (a)  Coverage provided under this chapter for necessary care and treatment in a chemical dependency treatment center must be provided as if the care and treatment were provided in a hospital.
(b)  The department by rule shall adopt standards formulated and approved by the department and the Texas Commission on Alcohol and Drug Abuse for use by insurers, other third-party reimbursement sources, and chemical dependency treatment centers.
(c)  Standards adopted under this section must provide for:
(1)  reasonable control of costs necessary for inpatient and outpatient treatment of chemical dependency, including guidelines for treatment periods;  and
(2)  appropriate utilization review of treatment as well as necessary extensions of treatment.
(d)  Coverage required under this chapter is subject to the standards adopted under this section.
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 1368 - Availability of Chemical Dependency Coverage › Section 1368.008. Use of Endorsement or Rider to Comply With Chapter

Sec. 1368.008.  USE OF ENDORSEMENT OR RIDER TO COMPLY WITH CHAPTER.  A group health benefit plan issuer that uses a policy form approved by the commissioner before November 10, 1981, may use an endorsement or rider to comply with this chapter if the endorsement or rider is approved by the commissioner as complying with this chapter and other provisions of this code.
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 A. Coverage of Prescription Drugs in General › Section 1369.001. Definitions

Sec. 1369.001.  DEFINITIONS.  In this subchapter:
(1)  "Contraindication" means the potential for, or the occurrence of:
(A)  an undesirable change in the therapeutic effect of a prescribed drug because of the presence of a disease condition in the patient for whom the drug is prescribed;  or
(B)  a clinically significant adverse effect of a prescribed drug on a disease condition of the patient for whom the drug is prescribed.
(2)  "Drug" has the meaning assigned by Section 551.003, Occupations Code.
(2-a)  "Enrollee" means an individual who is covered under a health benefit plan, including a covered dependent.
(3)  "Indication" means a symptom, cause, or occurrence in a disease that points out the cause, diagnosis, course of treatment, or prognosis of the disease.
(4)  "Peer-reviewed medical literature" means scientific studies published in a peer-reviewed national professional journal.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2017, 85th Leg., R.S., Ch. 727 (S.B. 1076), 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 A. Coverage of Prescription Drugs in General › Section 1369.002. Applicability of Subchapter

Sec. 1369.002.  APPLICABILITY OF SUBCHAPTER.  This subchapter applies only to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or 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.
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 A. Coverage of Prescription Drugs in General › Section 1369.003. Exception

Sec. 1369.003.  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), as amended;
(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 1369.002.
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 A. Coverage of Prescription Drugs in General › Section 1369.004. Coverage Required

Sec. 1369.004.  COVERAGE REQUIRED.  (a)  A health benefit plan that covers drugs must cover any drug prescribed to treat an enrollee for a chronic, disabling, or life-threatening illness covered under the plan if the drug:
(1)  has been approved by the United States Food and Drug Administration for at least one indication;  and
(2)  is recognized by the following for treatment of the indication for which the drug is prescribed:
(A)  a prescription drug reference compendium approved by the commissioner for purposes of this section;  or
(B)  substantially accepted peer-reviewed medical literature.
(b)  Coverage of a drug required under Subsection (a) must include coverage of medically necessary services associated with the administration of the drug.
(c)  A health benefit plan issuer may not, based on a "medical necessity" requirement, deny coverage of a drug required under Subsection (a) unless the reason for the denial is unrelated to the legal status of the drug use.
(d)  This section does not require a health benefit plan to cover:
(1)  experimental drugs that are not otherwise approved for an indication by the United States Food and Drug Administration;
(2)  any disease or condition that is excluded from coverage under the plan;  or
(3)  a drug that the United States Food and Drug Administration has determined to be contraindicated for treatment of the current indication.
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 A. Coverage of Prescription Drugs in General › Section 1369.0041. Certain Payments and Refills

Sec. 1369.0041.  CERTAIN PAYMENTS AND REFILLS.  (a)  A health benefit plan issuer that covers prescription drugs may not require an enrollee to make a payment for a prescription drug at the point of sale in an amount greater than the lesser of:
(1)  the applicable copayment;
(2)  the allowable claim amount for the prescription drug; or
(3)  the amount an individual would pay for the drug if the individual purchased the drug without using a health benefit plan or any other source of drug benefits or discounts.
(b)  A health benefit plan that covers prescription eye drops to treat a chronic eye disease or condition must allow the refill of prescription eye drops if the enrollee timely pays at the point of sale the maximum amount allowed by Subsection (a) and:
(1)  the original prescription states that additional quantities of the eye drops are needed;
(2)  the refill does not exceed the total quantity of dosage units authorized by the prescribing provider on the original prescription, including refills; and
(3)  the refill is dispensed on or before the last day of the prescribed dosage period and:
(A)  not earlier than the 21st day after the date a prescription for a 30-day supply of eye drops is dispensed;
(B)  not earlier than the 42nd day after the date a prescription for a 60-day supply of eye drops is dispensed; or
(C)  not earlier than the 63rd day after the date a prescription for a 90-day supply of eye drops is dispensed.
Added by Acts 2017, 85th Leg., R.S., Ch. 727 (S.B. 1076), 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 A. Coverage of Prescription Drugs in General › Section 1369.005. Rules

Sec. 1369.005.  RULES.  The commissioner may adopt rules to implement this subchapter.
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 B. Requirements Affecting Coverage of Specific Prescription Drugs or Cost Sharing › Section 1369.051. Definitions

Sec. 1369.051.  DEFINITIONS.  In this subchapter:
(1)  "Clinical practice guideline" means a statement systematically developed by a multidisciplinary panel of experts composed of physicians and, as necessary, other health care providers to assist a patient or health care provider in making a decision about appropriate health care for a specific clinical circumstance or condition.
(1-a)  "Clinical review criteria" means the written screening procedures, decision abstracts, clinical protocols, and clinical practice guidelines used by a health benefit plan issuer, utilization review organization, or independent review organization to determine the medical necessity and appropriateness or the experimental or investigational nature of a health care service or prescription drug.
(1-b)  "Drug formulary" means a list of drugs:
(A)  for which a health benefit plan provides coverage;
(B)  for which a health benefit plan issuer approves payment; or
(C)  that a health benefit plan issuer encourages or offers incentives for physicians to prescribe.
(2)  "Enrollee" means an individual who is covered under a health benefit plan, including a covered dependent.
(3)  "Physician" means a person licensed as a physician by the Texas State Board of Medical Examiners.
(4)  "Prescription drug" has the meaning assigned by Section 551.003, Occupations Code.
(5)  "Step therapy protocol" means a protocol that requires an enrollee to use a prescription drug or sequence of prescription drugs other than the drug that the enrollee's physician recommends for the enrollee's treatment before the health benefit plan provides coverage for the recommended drug.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 501 (H.B. 1405), Sec. 1, eff. September 1, 2011.
Acts 2017, 85th Leg., R.S., Ch. 103 (S.B. 680), Sec. 1, eff. September 1, 2017.
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. Requirements Affecting Coverage of Specific Prescription Drugs or Cost Sharing › Section 1369.052. Applicability of Subchapter

Sec. 1369.052.  APPLICABILITY OF SUBCHAPTER.  This subchapter applies only to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or a small or large employer group contract or similar coverage document that is offered by:
(1)  an insurance company;
(2)  a group hospital service corporation operating under Chapter 842;
(3)  a fraternal benefit society operating under Chapter 885;
(4)  a stipulated premium company operating under Chapter 884;
(5)  a reciprocal exchange operating under Chapter 942;
(6)  a health maintenance organization operating under Chapter 843;
(7)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846; or
(8)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 501 (H.B. 1405), Sec. 2, eff. September 1, 2011.
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. Requirements Affecting Coverage of Specific Prescription Drugs or Cost Sharing › Section 1369.053. Exception

Text of section effective until April 01, 2025
Sec. 1369.053.  EXCEPTION.  This subchapter does not apply to:
(1)  a health benefit plan that provides coverage:
(A)  only for a specified disease or for another single benefit;
(B)  only for accidental death or dismemberment;
(C)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury;
(D)  as a supplement to a liability insurance policy;
(E)  for credit insurance;
(F)  only for dental or vision care;
(G)  only for hospital expenses; or
(H)  only for indemnity for hospital confinement;
(2)   a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss), as amended;
(3)  a workers' compensation insurance policy;
(4)  medical payment insurance coverage provided under a motor vehicle insurance policy;
(5)  a long-term care insurance policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Section 1369.052;
(6)  the child health plan program under Chapter 62, Health and Safety Code, or the health benefits plan for children under Chapter 63, Health and Safety Code; or
(7)  a Medicaid managed care program operated under Chapter 533, Government Code, or a Medicaid program operated under Chapter 32, Human Resources Code.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 501 (H.B. 1405), Sec. 3, eff. September 1, 2011.
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.125, 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 B. Requirements Affecting Coverage of Specific Prescription Drugs or Cost Sharing › Section 1369.053. Exception

Text of section effective on April 01, 2025
Sec. 1369.053.  EXCEPTION.  This subchapter does not apply to:
(1)  a health benefit plan that provides coverage:
(A)  only for a specified disease or for another single benefit;
(B)  only for accidental death or dismemberment;
(C)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury;
(D)  as a supplement to a liability insurance policy;
(E)  for credit insurance;
(F)  only for dental or vision care;
(G)  only for hospital expenses; or
(H)  only for indemnity for hospital confinement;
(2)  a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss), as amended;
(3)  a workers' compensation insurance policy;
(4)  medical payment insurance coverage provided under a motor vehicle insurance policy;
(5)  a long-term care insurance policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Section 1369.052;
(6)  the child health plan program under Chapter 62, Health and Safety Code, or the health benefits plan for children under Chapter 63, Health and Safety Code; or
(7)  a Medicaid managed care program operated under Chapter 540 or 540A, Government Code, as applicable, or a Medicaid program operated under Chapter 32, Human Resources Code.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 501 (H.B. 1405), Sec. 3, eff. September 1, 2011.
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.125, 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 B. Requirements Affecting Coverage of Specific Prescription Drugs or Cost Sharing › Section 1369.054. Notice and Disclosure of Certain Information Required

Sec. 1369.054.  NOTICE AND DISCLOSURE OF CERTAIN INFORMATION REQUIRED.  An issuer of a health benefit plan that covers prescription drugs and uses one or more drug formularies to specify the prescription drugs covered under the plan shall:
(1)  provide in plain language in the coverage documentation provided to each enrollee:
(A)  notice that the plan uses one or more drug formularies;
(B)  an explanation of what a drug formulary is;
(C)  a statement regarding the method the issuer uses to determine the prescription drugs to be included in or excluded from a drug formulary;
(D)  a statement of how often the issuer reviews the contents of each drug formulary; and
(E)  notice that an enrollee may contact the issuer to determine whether a specific drug is included in a particular drug formulary;
(2)  disclose to an individual on request, not later than the third business day after the date of the request, whether a specific drug is included in a particular drug formulary; and
(3)  notify an enrollee and any other individual who requests information under this section that the inclusion of a drug in a drug formulary does not guarantee that an enrollee's health care provider will prescribe that drug for a particular medical condition or mental illness.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 501 (H.B. 1405), Sec. 4, eff. September 1, 2011.
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. Requirements Affecting Coverage of Specific Prescription Drugs or Cost Sharing › Section 1369.0541. Modification of Drug Coverage Under Plan

Sec. 1369.0541.  MODIFICATION OF DRUG COVERAGE UNDER PLAN.  (a)  A health benefit plan issuer may modify drug coverage provided under a health benefit plan if:
(1)  the modification occurs at the time of coverage renewal;
(2)  the modification is effective uniformly among all group health benefit plan sponsors covered by identical or substantially identical health benefit plans or all individuals covered by identical or substantially identical individual health benefit plans, as applicable; and
(3)  not later than the 60th day before the date the modification is effective, the issuer provides written notice of the modification to the commissioner, each affected group health benefit plan sponsor, each affected enrollee in an affected group health benefit plan, and each affected individual health benefit plan holder.
(b)  Modifications affecting drug coverage that require notice under Subsection (a) include:
(1)  removing a drug from a formulary;
(2)  adding a requirement that an enrollee receive prior authorization for a drug;
(3)  imposing or altering a quantity limit for a drug;
(4)  imposing a step-therapy restriction for a drug; and
(5)  moving a drug to a higher cost-sharing tier unless a generic drug alternative to the drug is available.
(c)  A health benefit plan issuer may elect to offer an enrollee in the plan the option of receiving notifications required by this section by e-mail.
Added by Acts 2011, 82nd Leg., R.S., Ch. 501 (H.B. 1405), Sec. 5, eff. September 1, 2011.
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. Requirements Affecting Coverage of Specific Prescription Drugs or Cost Sharing › Section 1369.0542. Effect of Reductions in Out-of-Pocket Expenses on Cost Sharing

Sec. 1369.0542.  EFFECT OF REDUCTIONS IN OUT-OF-POCKET EXPENSES ON COST SHARING.  (a)  This section applies only to a reduction in out-of-pocket expenses made by or on behalf of an enrollee for a prescription drug covered by the enrollee's health benefit plan for which:
(1)  a generic equivalent does not exist;
(2)  a generic equivalent does exist but the enrollee has obtained access to the prescription drug under the enrollee's health benefit plan using:
(A)  a prior authorization process;
(B)  a step therapy protocol; or
(C)  the health benefit plan issuer's exceptions and appeals process;
(3)  an interchangeable biological product does not exist; or
(4)  an interchangeable biological product does exist but the enrollee has obtained access to the prescription drug under the enrollee's health benefit plan using:
(A)  a prior authorization process;
(B)  a step therapy protocol; or
(C)  the health benefit plan issuer's exceptions and appeals process.
(b)  An issuer of a health benefit plan that covers prescription drugs or a pharmacy benefit manager shall apply any third-party payment, financial assistance, discount, product voucher, or other reduction in out-of-pocket expenses made by or on behalf of an enrollee for a prescription drug to the enrollee's deductible, copayment, cost-sharing responsibility, or out-of-pocket maximum applicable to health benefits under the enrollee's plan.
Added by Acts 2023, 88th Leg., R.S., Ch. 489 (H.B. 999), 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 B. Requirements Affecting Coverage of Specific Prescription Drugs or Cost Sharing › Section 1369.0545. Step Therapy Protocols

Sec. 1369.0545.  STEP THERAPY PROTOCOLS.  (a)  A health benefit plan issuer that requires a step therapy protocol before providing coverage for a prescription drug must establish, implement, and administer the step therapy protocol in accordance with clinical review criteria readily available to the health care industry.  The health benefit plan issuer shall take into account the needs of atypical patient populations and diagnoses in establishing the clinical review criteria.  The clinical review criteria:
(1)  must consider generally accepted clinical practice guidelines that are:
(A)  developed and endorsed by a multidisciplinary panel of experts described by Subsection (b);
(B)  based on high quality studies, research, and medical practice;
(C)  created by an explicit and transparent process that:
(i)  minimizes bias and conflicts of interest;
(ii)  explains the relationship between treatment options and outcomes;
(iii)  rates the quality of the evidence supporting the recommendations; and
(iv)  considers relevant patient subgroups and preferences; and
(D)  updated at appropriate intervals after a review of new evidence, research, and treatments; or
(2)  if clinical practice guidelines described by Subdivision (1) are not reasonably available, may be based on peer-reviewed publications developed by independent experts, which may include physicians, with expertise applicable to the relevant health condition.
(b)  A multidisciplinary panel of experts composed of physicians and, as necessary, other health care providers that develops and endorses clinical practice guidelines under Subsection (a)(1) must manage conflicts of interest by:
(1)  requiring each member of the panel's writing or review group to:
(A)  disclose any potential conflict of interest, including a conflict of interest involving an insurer, health benefit plan issuer, or pharmaceutical manufacturer; and
(B)  recuse himself or herself in any situation in which the member has a conflict of interest;
(2)  using a methodologist to work with writing groups to provide objectivity in data analysis and the ranking of evidence by preparing evidence tables and facilitating consensus; and
(3)  offering an opportunity for public review and comment.
(c)  Subsection (b) does not apply to a panel or committee of experts, including a pharmacy and therapeutics committee, established by a health benefit plan issuer or a pharmacy benefit manager that advises the health benefit plan issuer or pharmacy benefit manager regarding drugs or formularies.
Added by Acts 2017, 85th Leg., R.S., Ch. 103 (S.B. 680), Sec. 2, eff. September 1, 2017.
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. Requirements Affecting Coverage of Specific Prescription Drugs or Cost Sharing › Section 1369.0547. Step Therapy Protocols for Prescription Drugs to Treat Serious Mental Illnesses

Sec. 1369.0547.  STEP THERAPY PROTOCOLS FOR PRESCRIPTION DRUGS TO TREAT SERIOUS MENTAL ILLNESSES.  (a)  In this section, "serious  mental illness" has the meaning assigned by Section 1355.001.
(b)  This section applies only to a drug prescribed to an enrollee who is 18 years of age or older to treat a diagnosis of a serious mental illness.
(c)  A health benefit plan that provides coverage for prescription drugs to treat a serious mental illness 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 more than one different drug for each drug prescribed, excluding the generic or pharmaceutical equivalent of the prescribed drug; or
(2)  prove a history of failure of more than one different drug for each drug prescribed, excluding the generic or pharmaceutical equivalent of the prescribed drug.
(d)  Subject to Section 1369.0546, a health benefit plan issuer may implement a step therapy protocol to require a trial of a generic or pharmaceutical equivalent of a prescribed prescription drug as a condition of continued coverage of the prescribed drug only:
(1)  once in a plan year; and
(2)  if the generic or pharmaceutical equivalent drug is added to the plan's drug formulary.
Added by Acts 2023, 88th Leg., R.S., Ch. 684 (H.B. 1337), 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. Requirements Affecting Coverage of Specific Prescription Drugs or Cost Sharing › Section 1369.055. Continuation of Coverage Required; Other Drugs Not Precluded

Sec. 1369.055.  CONTINUATION OF COVERAGE REQUIRED;  OTHER DRUGS NOT PRECLUDED. (a) An issuer of a health benefit plan that covers prescription drugs shall offer to each enrollee at the contracted benefit level and until the enrollee's plan renewal date any prescription drug that was approved or covered under the plan for a medical condition or mental illness, regardless of whether the drug has been removed from the health benefit plan's drug formulary before the plan renewal date.
(b)  This section does not prohibit a physician or other health professional who is authorized to prescribe a drug from prescribing a drug that is an alternative to a drug for which continuation of coverage is required under Subsection (a) if the alternative drug is:
(1)  covered under the health benefit plan; and
(2)  medically appropriate for the enrollee.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 501 (H.B. 1405), Sec. 6, eff. September 1, 2011.
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. Requirements Affecting Coverage of Specific Prescription Drugs or Cost Sharing › Section 1369.056. Adverse Determination

Sec. 1369.056.  ADVERSE DETERMINATION.  (a)  The refusal of a health benefit plan issuer to provide benefits to an enrollee for a prescription drug is an adverse determination for purposes of Section 4201.002 if:
(1)  the drug is not included in a drug formulary used by the health benefit plan; and
(2)  the enrollee's physician has determined that the drug is medically necessary.
(b)  The enrollee may appeal the adverse determination under Subchapters H and I, Chapter 4201.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2G.012, eff. April 1, 2009.
Acts 2011, 82nd Leg., R.S., Ch. 501 (H.B. 1405), Sec. 7, eff. September 1, 2011.
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. Requirements Affecting Coverage of Specific Prescription Drugs or Cost Sharing › Section 1369.057. Rules

Sec. 1369.057.  RULES.  The commissioner may adopt rules to implement this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
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 1369.076. Definitions

Sec. 1369.076.  DEFINITIONS.  In this subchapter, terms defined by Subchapter B have the meanings assigned by that subchapter.
Added by Acts 2017, 85th Leg., R.S., Ch. 135 (H.B. 1227), Sec. 1, eff. September 1, 2017.