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 1369.094. Disclosure of Prescription Drug Information

Sec. 1369.094.  DISCLOSURE OF PRESCRIPTION DRUG INFORMATION.  (a)  This section applies only with respect to a prescription drug covered under a health benefit plan's pharmacy benefit.
(b)  A health benefit plan issuer that covers prescription drugs shall provide information regarding a covered prescription drug to an enrollee or the enrollee's prescribing provider on request. The information provided must include the issuer's drug formulary and, for the prescription drug and any formulary alternative:
(1)  the enrollee's eligibility;
(2)  cost-sharing information, including any deductible, copayment, or coinsurance, which must:
(A)  be consistent with cost-sharing requirements under the enrollee's plan;
(B)  be accurate at the time the cost-sharing information is provided; and
(C)  include any variance in cost-sharing based on the patient's preferred dispensing retail or mail-order pharmacy or the prescribing provider; and
(3)  applicable utilization management requirements.
(c)  In providing the information required under Subsection (b), a health benefit plan issuer shall:
(1)  respond in real time to a request made through a standard API;
(2)  allow the use of an integrated technology or service as necessary to provide the required information;
(3)  ensure that the information provided is current no later than one business day after the date a change is made; and
(4)  provide the information if the request is made using the drug's unique billing code and National Drug Code.
(d)  A health benefit plan issuer may not:
(1)  deny or delay a response to a request for information under Subsection (b) for the purpose of blocking the release of the information;
(2)  restrict a prescribing provider from communicating to the enrollee the information provided under Subsection (b), information about the cash price of the drug, or any additional information on any lower cost or clinically appropriate alternative drug, whether or not the drug is covered under the enrollee's plan;
(3)  except as required by law, interfere with, prevent, or materially discourage access to or the exchange or use of the information provided under Subsection (b), including by:
(A)  charging a fee to access the information;
(B)  not responding to a request within the time required by this section; or
(C)  instituting a consent requirement for an enrollee to access the information; or
(4)  penalize, including by taking any action intended to punish or discourage future similar behavior by the prescribing provider, a prescribing provider for:
(A)  disclosing the information provided under Subsection (b); or
(B)  prescribing, administering, or ordering a lower cost or clinically appropriate alternative drug.
(e)  A health benefit plan issuer with fewer than 10,000 enrollees may:
(1)  register with the department to receive an additional 12 months after the effective date of this subchapter to comply with the requirements of this subchapter; and
(2)  after the additional 12 months provided for in Subdivision (1), request from the department a temporary exception from one or more requirements of this section by submitting a report to the department that demonstrates that compliance would impose an unreasonable cost relative to the public value that would be gained from full compliance.
Added by Acts 2023, 88th Leg., R.S., Ch. 272 (S.B. 622), Sec. 1, eff. September 1, 2023.