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 F. Audits of Pharmacists and Pharmacies › Section 1369.259. Calculation of Recoupment; Use of Extrapolation Prohibited

Sec. 1369.259.  CALCULATION OF RECOUPMENT; USE OF EXTRAPOLATION PROHIBITED.  (a)  A health benefit plan issuer or pharmacy benefit manager may not calculate the amount of a recoupment based on:
(1)  an absence of documentation the pharmacist or pharmacy is not required by applicable federal laws and regulations and state laws and rules to maintain; or
(2)  an error that does not result in actual financial harm to the patient or enrollee, the health benefit plan issuer, or the pharmacy benefit manager.
(b)  A health benefit plan issuer or pharmacy benefit manager may not require extrapolation audits as a condition of participation in a contract, network, or program for a pharmacist or pharmacy.
(c)  A health benefit plan issuer or pharmacy benefit manager may not use extrapolation to complete an on-site audit or a desk audit of a pharmacist or pharmacy.  Notwithstanding Subsection (a)(2), the amount of a recoupment must be based on the actual overpayment or underpayment and may not be based on an extrapolation.
(d)  A health benefit plan issuer or pharmacy benefit manager may not include a dispensing fee amount in the calculation of an overpayment unless:
(1)  the fee was a duplicate charge;
(2)  the prescription for which the fee was charged:
(A)  was not dispensed; or
(B)  was dispensed:
(i)  without the prescriber's authorization;
(ii)  to the wrong patient; or
(iii)  with the wrong instructions; or
(3)  the wrong drug was dispensed.
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 1369.260. Clerical or Recordkeeping Error; Fraud Allegation

Sec. 1369.260.  CLERICAL OR RECORDKEEPING ERROR; FRAUD ALLEGATION.  (a) An unintentional clerical or recordkeeping error, such as a typographical error, scrivener's error, or computer error, found during an on-site audit or a desk audit:
(1)  is not prima facie evidence of fraud or intentional misrepresentation; and
(2)  may not be the basis of a recoupment unless the error results in actual financial harm to a patient or enrollee, health benefit plan issuer, or pharmacy benefit manager.
(b)  If the health benefit plan issuer or pharmacy benefit manager alleges that the pharmacist or pharmacy committed fraud or intentional misrepresentation described by Subsection (a), the health benefit plan issuer or pharmacy benefit manager must state the allegation in the final audit report required by Section 1369.264.
(c)  After an audit is initiated, a pharmacist or pharmacy may resubmit a claim described by Subsection (a) if the deadline for submission of a claim under Section 843.337 or 1301.102 has not expired.
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 1369.261. Access to Previous Audit Reports; Uniform Audit Standards

Sec. 1369.261.  ACCESS TO PREVIOUS AUDIT REPORTS; UNIFORM AUDIT STANDARDS.  (a)  Except as provided by Subsection (b), a health benefit plan issuer or pharmacy benefit manager may have access to an audit report of a pharmacist or pharmacy only if the report was prepared in connection with an audit conducted by the health benefit plan issuer or pharmacy benefit manager.
(b)  A health benefit plan issuer or pharmacy benefit manager may have access to audit reports other than the reports described by Subsection (a) if, after reviewing claims data, written or oral statements of pharmacy staff, wholesalers, or others, or other investigative information, including patient referrals, anonymous reports, or postings on Internet websites, the plan issuer or the pharmacy benefit manager suspects the audited pharmacist or pharmacy committed fraud or made an intentional misrepresentation related to the pharmacy business.
(c)  An auditor must conduct an on-site audit or a desk audit of similarly situated pharmacists or pharmacies under the same audit standards.
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 1369.262. Compensation of Auditor

Sec. 1369.262.  COMPENSATION OF AUDITOR.  An individual performing an on-site audit or a desk audit may not directly or indirectly receive compensation based on a percentage of the amount recovered as a result of the audit.
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 1369.263. Conclusion of Audit; Summary; Preliminary Audit Report

Sec. 1369.263.  CONCLUSION OF AUDIT; SUMMARY; PRELIMINARY AUDIT REPORT.  (a)  At the conclusion of an on-site audit or a desk audit, the health benefit plan issuer or pharmacy benefit manager shall:
(1)  provide to the pharmacist or pharmacy a summary of the audit findings; and
(2)  allow the pharmacist or pharmacy to respond to questions and alleged discrepancies, if any, and comment on and clarify the findings.
(b)  Not later than the 60th day after the date the audit is concluded, the health benefit plan issuer or pharmacy benefit manager shall send by a means that allows tracking of delivery to the pharmacist or pharmacy a preliminary audit report stating the results of the audit and a list identifying documentation, if any, required to resolve discrepancies, if any, found as a result of the audit.
(c)  The pharmacist or pharmacy may, by providing documentation or otherwise, challenge a result or remedy a discrepancy stated in the preliminary audit report not later than the 30th day after the date the pharmacist or pharmacy receives the report.
(d)  The pharmacist or pharmacy may request an extension to provide documentation supporting a challenge.  The request shall be reasonably granted.  A health benefit plan issuer or pharmacy benefit manager that grants an extension is not subject to the deadline to send the final audit report under Section 1369.264.
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 1369.264. Final Audit Report

Sec. 1369.264.  FINAL AUDIT REPORT.  Not later than the 120th day after the date the pharmacist or pharmacy receives a preliminary audit report under Section 1369.263, the health benefit plan issuer or pharmacy benefit manager shall send by a means that allows tracking of delivery to the pharmacist or pharmacy a final audit report that states:
(1)  the audit results after review of the documentation submitted by the pharmacist or pharmacy in response to the preliminary audit report; and
(2)  the audit results, including a description of all alleged discrepancies and explanations for and the amount of recoupments claimed after consideration of the pharmacist's or pharmacy's response to the preliminary audit report.
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 1369.265. Certain Audits Exempt From Deadlines

Sec. 1369.265.  CERTAIN AUDITS EXEMPT FROM DEADLINES.  A health benefit plan issuer or pharmacy benefit manager is not subject to the deadlines for sending a report under Sections 1369.263 and 1369.264 if, after reviewing claims data, written or oral statements of pharmacy staff, wholesalers, or others, or other investigative information, including patient referrals, anonymous reports, or postings on Internet websites, the plan issuer or pharmacy benefit manager suspects the audited pharmacist or pharmacy committed fraud or made an intentional misrepresentation related to the pharmacy business.
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 1369.266. Recoupment and Interest Charged After Audit

Sec. 1369.266.  RECOUPMENT AND INTEREST CHARGED AFTER AUDIT.  (a)  If an audit under this subchapter is conducted, the health benefit plan issuer or pharmacy benefit manager:
(1)  may recoup from the pharmacist or pharmacy an amount based only on a final audit report; and
(2)  may not accrue or assess interest on an amount due until the date the pharmacist or pharmacy receives the final audit report under Section 1369.264.
(b)  The limitations on recoupment and interest accrual or assessment under Subsection (a) do not apply to a health benefit plan issuer or pharmacy benefit manager that, after reviewing claims data, written or oral statements of pharmacy staff, wholesalers, or others, or other investigative information, including patient referrals, anonymous reports, or postings on Internet websites, suspects the audited pharmacist or pharmacy committed fraud or made an intentional misrepresentation related to the pharmacy business.
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 1369.267. Waiver Prohibited

Sec. 1369.267.  WAIVER PROHIBITED.  The provisions of this subchapter may not be waived, voided, or nullified by contract.
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 1369.268. Remedies Not Exclusive

Sec. 1369.268.  REMEDIES NOT EXCLUSIVE.  This subchapter may not be construed to waive a remedy at law available to a 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 1369.269. Enforcement; Rules

Sec. 1369.269.  ENFORCEMENT; RULES.  The commissioner may enforce this subchapter and adopt and enforce reasonable rules necessary to accomplish the purposes of this subchapter.
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 1369.270. Legislative Declaration

Sec. 1369.270.  LEGISLATIVE DECLARATION.  Except as provided by Section 1369.252, it is the intent of the legislature that the requirements contained in this subchapter regarding the audit of claims to providers who are pharmacists or pharmacies apply to all health benefit plan issuers and pharmacy benefit managers unless otherwise prohibited by federal law.
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 G. Standard Request Form for Prior Authorization of Prescription Drug Benefits › Section 1369.301. Definition

Sec. 1369.301.  DEFINITION.  In this subchapter, "prescription drug" has the meaning assigned by Section 551.003, Occupations Code.
Added by Acts 2013, 83rd Leg., R.S., Ch. 1328 (S.B. 644), Sec. 1, eff. September 1, 2013.
Redesignated from Insurance Code, Section 1369.251 by Acts 2015, 84th Leg., R.S., Ch. 1236 (S.B. 1296), Sec. 21.001(38), eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services › Subchapter G. Standard Request Form for Prior Authorization of Prescription Drug Benefits › Section 1369.302. Applicability of Subchapter

Sec. 1369.302.  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 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.
(b)  This subchapter applies to group health coverage made available by a school district in accordance with Section 22.004, Education Code.
(c)  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.
(d)  Notwithstanding any other law, this subchapter applies to coverage under:
(1)  the child health plan program under Chapter 62, Health and Safety Code, or the health benefits plan for children under Chapter 63, Health and Safety Code; and
(2)  the medical assistance program under Chapter 32, Human Resources Code.
Added by Acts 2013, 83rd Leg., R.S., Ch. 1328 (S.B. 644), Sec. 1, eff. September 1, 2013.
Redesignated from Insurance Code, Section 1369.252 by Acts 2015, 84th Leg., R.S., Ch. 1236 (S.B. 1296), Sec. 21.001(38), eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services › Subchapter G. Standard Request Form for Prior Authorization of Prescription Drug Benefits › Section 1369.303. Exception

Sec. 1369.303.  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);
(3)  medical payment insurance coverage provided under a motor vehicle insurance policy;
(4)  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 1369.302;
(5)  health and accident coverage provided by a risk pool created under Chapter 172, Local Government Code; or
(6)  a workers' compensation insurance policy.
Added by Acts 2013, 83rd Leg., R.S., Ch. 1328 (S.B. 644), Sec. 1, eff. September 1, 2013.
Redesignated from Insurance Code, Section 1369.253 by Acts 2015, 84th Leg., R.S., Ch. 1236 (S.B. 1296), Sec. 21.001(38), eff. September 1, 2015.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1236 (S.B. 1296), Sec. 21.002(14), eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services › Subchapter G. Standard Request Form for Prior Authorization of Prescription Drug Benefits › Section 1369.304. Standard Form

Sec. 1369.304.  STANDARD FORM.  (a)  The commissioner by rule shall:
(1)  prescribe a single, standard form for requesting prior authorization of prescription drug benefits;
(2)  require a health benefit plan issuer or the agent of the health benefit plan issuer that manages or administers prescription drug benefits to use the form for any prior authorization of prescription drug benefits required by the plan;
(3)  require that the department and a health benefit plan issuer or the agent of the health benefit plan issuer that manages or administers prescription drug benefits make the form available electronically on the website of:
(A)  the department;
(B)  the health benefit plan issuer; and
(C)  the agent of the health benefit plan issuer; and
(4)  establish penalties for failure to accept the form and acknowledge receipt of the form as required by commissioner rule.
(b)  Not later than the second anniversary of the date national standards for electronic prior authorization of benefits are adopted, a health benefit plan issuer or the agent of the health benefit plan issuer that manages or administers prescription drug benefits shall exchange prior authorization requests electronically with a prescribing provider who has e-prescribing capability and who initiates a request electronically.
(c)  In prescribing a form under this section, the commissioner shall:
(1)  develop the form with input from the advisory committee on uniform prior authorization forms established under Section 1369.305; and
(2)  take into consideration:
(A)  any form for requesting prior authorization of benefits that is widely used in this state or any form currently used by the department;
(B)  request forms for prior authorization of benefits established by the federal Centers for Medicare and Medicaid Services; and
(C)  national standards, or draft standards, pertaining to electronic prior authorization of benefits.
Added by Acts 2013, 83rd Leg., R.S., Ch. 1328 (S.B. 644), Sec. 1, eff. September 1, 2013.
Redesignated from Insurance Code, Section 1369.254 by Acts 2015, 84th Leg., R.S., Ch. 1236 (S.B. 1296), Sec. 21.001(38), eff. September 1, 2015.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1236 (S.B. 1296), Sec. 21.002(15), eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services › Subchapter G. Standard Request Form for Prior Authorization of Prescription Drug Benefits › Section 1369.306. Failure to Use or Acknowledge Standard Form

Sec. 1369.306.  FAILURE TO USE OR ACKNOWLEDGE STANDARD FORM.  If a health benefit plan issuer or the agent of the health benefit plan issuer that manages or administers prescription drug benefits fails to use or accept the form prescribed under this subchapter or fails to acknowledge the receipt of a completed form submitted by a prescribing provider, as required by commissioner rule, the health benefit plan issuer or the agent of the health benefit plan issuer is subject to the penalties established by the commissioner.
Added by Acts 2013, 83rd Leg., R.S., Ch. 1328 (S.B. 644), Sec. 1, eff. September 1, 2013.
Redesignated from Insurance Code, Section 1369.256 by Acts 2015, 84th Leg., R.S., Ch. 1236 (S.B. 1296), Sec. 21.001(38), eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services › Subchapter H. Maximum Allowable Cost › Section 1369.351. Definitions

Sec. 1369.351.  DEFINITIONS.  In this subchapter:
(1)  "Health benefit plan" has the meaning assigned by Section 1369.251, as added by Chapter 915 (H.B. 1358), Acts of the 83rd Legislature, Regular Session, 2013.
(2)  "Pharmacy benefit manager" has the meaning assigned by Section 4151.151.
Added by Acts 2015, 84th Leg., R.S., Ch. 596 (S.B. 332), Sec. 1, eff. January 1, 2016.
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 H. Maximum Allowable Cost › Section 1369.352. Certain Benefits Excluded

Text of section effective until April 01, 2025
Sec. 1369.352. CERTAIN BENEFITS EXCLUDED.  This subchapter does not apply to maximum allowable costs for pharmacy benefits provided under:
(1)  a Medicaid managed care program operated under Chapter 533, Government Code;
(2)  a Medicaid program operated under Chapter 32, Human Resources Code;
(3)  the child health plan program under Chapter 62, Health and Safety Code;
(4)  the health benefits plan for children under Chapter 63, Health and Safety Code;
(5)  a health benefit plan issued under Chapter 1551, 1575, 1579, or 1601; or
(6)  a workers' compensation insurance policy or other form of providing medical benefits under Title 5, Labor Code.
Added by Acts 2015, 84th Leg., R.S., Ch. 596 (S.B. 332), Sec. 1, eff. January 1, 2016.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.127, 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 H. Maximum Allowable Cost › Section 1369.352. Certain Benefits Excluded

Text of section effective on April 01, 2025
Sec. 1369.352.  CERTAIN BENEFITS EXCLUDED.  This subchapter does not apply to maximum allowable costs for pharmacy benefits provided under:
(1)  a Medicaid managed care program operated under Chapter 540 or 540A, Government Code, as applicable;
(2)  a Medicaid program operated under Chapter 32, Human Resources Code;
(3)  the child health plan program under Chapter 62, Health and Safety Code;
(4)  the health benefits plan for children under Chapter 63, Health and Safety Code;
(5)  a health benefit plan issued under Chapter 1551, 1575, 1579, or 1601; or
(6)  a workers' compensation insurance policy or other form of providing medical benefits under Title 5, Labor Code.
Added by Acts 2015, 84th Leg., R.S., Ch. 596 (S.B. 332), Sec. 1, eff. January 1, 2016.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.127, 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 H. Maximum Allowable Cost › Section 1369.353. Criteria for Drugs on Maximum Allowable Cost Lists

Sec. 1369.353.  CRITERIA FOR DRUGS ON MAXIMUM ALLOWABLE COST LISTS.  A health benefit plan issuer or pharmacy benefit manager may not include a drug on a maximum allowable cost list unless:
(1)  the drug:
(A)  has an "A" or "B" rating in the most recent version of the United States Food and Drug Administration's Approved Drug Products with Therapeutic Equivalence Evaluations, also known as the Orange Book; or
(B)  is rated "NR" or "NA" or has a similar rating by a nationally recognized reference; and
(2)  the drug is:
(A)  generally available for purchase by pharmacists and pharmacies in this state from a national or regional wholesaler; and
(B)  not obsolete.
Added by Acts 2015, 84th Leg., R.S., Ch. 596 (S.B. 332), Sec. 1, eff. January 1, 2016.
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 H. Maximum Allowable Cost › Section 1369.354. Formulation of Maximum Allowable Costs; Disclosures

Sec. 1369.354.  FORMULATION OF MAXIMUM ALLOWABLE COSTS; DISCLOSURES.  (a)  In formulating the maximum allowable cost price for a drug, a health benefit plan issuer or pharmacy benefit manager may only use the price of that drug and any drug listed as therapeutically equivalent to that drug in the most recent version of the United States Food and Drug Administration's Approved Drug Products with Therapeutic Equivalence Evaluations, also known as the Orange Book.
(b)  Notwithstanding Subsection (a), if a therapeutically equivalent generic drug is unavailable or has limited market presence, a health benefit plan issuer or pharmacy benefit manager may place on a maximum allowable cost list a drug that has:
(1)  a "B" rating in the most recent version of the United States Food and Drug Administration's Approved Drug Products with Therapeutic Equivalence Evaluations, also known as the Orange Book; or
(2)  an "NR" or "NA" rating or a similar rating by a nationally recognized reference.
(c)  A health benefit plan issuer or pharmacy benefit manager must, in accordance with Subsection (d), disclose to a pharmacist or pharmacy the sources of the pricing data used in formulating maximum allowable cost prices.
(d)  The information described by Subsection (c) must be disclosed:
(1)  on the date the health benefit plan issuer or pharmacy benefit manager enters into the contract with the pharmacist or pharmacy; and
(2)  after that contract date, on the request of the pharmacist or pharmacy.
Added by Acts 2015, 84th Leg., R.S., Ch. 596 (S.B. 332), Sec. 1, eff. January 1, 2016.
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 H. Maximum Allowable Cost › Section 1369.355. Updates

Sec. 1369.355.  UPDATES.  (a)  A health benefit plan issuer or pharmacy benefit manager shall establish a process that will in a timely manner eliminate drugs from maximum allowable cost lists or modify maximum allowable cost prices to remain consistent with changes in pricing data used in formulating maximum allowable cost prices and product availability.
(b)  A health benefit plan issuer or pharmacy benefit manager shall review and update maximum allowable cost price information for each drug at least once every seven days to reflect any modification of maximum allowable cost pricing.
Added by Acts 2015, 84th Leg., R.S., Ch. 596 (S.B. 332), Sec. 1, eff. January 1, 2016.
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 H. Maximum Allowable Cost › Section 1369.356. Access to Maximum Allowable Cost Lists

Sec. 1369.356.  ACCESS TO MAXIMUM ALLOWABLE COST LISTS.  A health benefit plan issuer or pharmacy benefit manager must provide to each pharmacist or pharmacy under contract with the health benefit plan issuer or pharmacy benefit manager a process to readily access the maximum allowable cost list that applies to the pharmacist or pharmacy.
Added by Acts 2015, 84th Leg., R.S., Ch. 596 (S.B. 332), Sec. 1, eff. January 1, 2016.
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 H. Maximum Allowable Cost › Section 1369.357. Appeal From Maximum Allowable Cost Price Determination

Sec. 1369.357.  APPEAL FROM MAXIMUM ALLOWABLE COST PRICE DETERMINATION.  (a)  A health benefit plan issuer or pharmacy benefit manager must provide in the contract with each pharmacist or pharmacy a procedure for the pharmacist or pharmacy to appeal a maximum allowable cost price of a drug on or before the 10th day after the date a pharmacy benefit claim for the drug is made.
(b)  The health benefit plan issuer or pharmacy benefit manager shall respond to an appeal described by Subsection (a) in a documented communication not later than the 10th day after the date the appeal is received by the health benefit plan issuer or pharmacy benefit manager.
(c)  If the appeal is successful, the health benefit plan issuer or pharmacy benefit manager shall:
(1)  adjust the maximum allowable cost price that is the subject of the appeal effective on the day after the date the appeal is decided;
(2)  apply the adjusted maximum allowable cost price to all similarly situated pharmacists and pharmacies as determined by the health benefit plan issuer or pharmacy benefit manager; and
(3)  allow the pharmacist or pharmacy that succeeded in the appeal to reverse and rebill the pharmacy benefit claim giving rise to the appeal.
(d)  If the appeal is not successful, the health benefit plan issuer or pharmacy benefit manager shall disclose to the pharmacist or pharmacy:
(1)  each reason the appeal is denied; and
(2)  the national drug code number from the national or regional wholesalers from which the drug is generally available for purchase by pharmacists and pharmacies in this state at the maximum allowable cost price that is the subject of the appeal.
Added by Acts 2015, 84th Leg., R.S., Ch. 596 (S.B. 332), Sec. 1, eff. January 1, 2016.
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 H. Maximum Allowable Cost › Section 1369.358. Confidentiality of Maximum Allowable Cost List

Sec. 1369.358.  CONFIDENTIALITY OF MAXIMUM ALLOWABLE COST LIST.  A maximum allowable cost list that applies to a pharmacist or pharmacy and is maintained by a health benefit plan issuer or pharmacy benefit manager is confidential.  This section may not be construed to alter a health benefit plan issuer's or pharmacy benefit manager's obligations under Section 1369.356.
Added by Acts 2015, 84th Leg., R.S., Ch. 596 (S.B. 332), Sec. 1, eff. January 1, 2016.
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 H. Maximum Allowable Cost › Section 1369.359. Waiver Prohibited

Sec. 1369.359.  WAIVER PROHIBITED.  The provisions of this subchapter may not be waived, voided, or nullified by contract.
Added by Acts 2015, 84th Leg., R.S., Ch. 596 (S.B. 332), Sec. 1, eff. January 1, 2016.
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 H. Maximum Allowable Cost › Section 1369.360. Remedies Not Exclusive

Sec. 1369.360.  REMEDIES NOT EXCLUSIVE.  This subchapter may not be construed to waive a remedy at law available to a pharmacist or pharmacy.
Added by Acts 2015, 84th Leg., R.S., Ch. 596 (S.B. 332), Sec. 1, eff. January 1, 2016.
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 H. Maximum Allowable Cost › Section 1369.361. Enforcement

Sec. 1369.361.  ENFORCEMENT.  The commissioner shall enforce this subchapter.
Added by Acts 2015, 84th Leg., R.S., Ch. 596 (S.B. 332), Sec. 1, eff. January 1, 2016.
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 H. Maximum Allowable Cost › Section 1369.362. Legislative Declaration

Sec. 1369.362.  LEGISLATIVE DECLARATION.  It is the intent of the legislature that, except with respect to the benefits excluded under Section 1369.352, the requirements contained in this subchapter apply to all health benefit plan issuers and pharmacy benefit managers unless otherwise prohibited by federal law.
Added by Acts 2015, 84th Leg., R.S., Ch. 596 (S.B. 332), Sec. 1, eff. January 1, 2016.
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 I. Pharmacy Benefit Claim Adjudication › Section 1369.401. Definition

Sec. 1369.401.  DEFINITION.  In this subchapter, "pharmacy benefit manager" has the meaning assigned by Section 4151.151.
Added by Acts 2015, 84th Leg., R.S., Ch. 10 (S.B. 94), Sec. 1, eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services › Subchapter I. Pharmacy Benefit Claim Adjudication › Section 1369.402. Certain Fees Prohibited

Sec. 1369.402.  CERTAIN FEES PROHIBITED.  A health benefit plan issuer or a pharmacy benefit manager may not directly or indirectly charge or hold a pharmacist or pharmacy responsible for a fee for any step of or component or mechanism related to the claim adjudication process, including:
(1)  the adjudication of a pharmacy benefit claim;
(2)  the processing or transmission of a pharmacy benefit claim;
(3)  the development or management of a claim processing or adjudication network; or
(4)  participation in a claim processing or adjudication network.
Added by Acts 2015, 84th Leg., R.S., Ch. 10 (S.B. 94), Sec. 1, eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services › Subchapter J. Coverage Related to Prescription Drug Synchronization › Section 1369.451. Definitions

Sec. 1369.451.  DEFINITIONS.  In this subchapter:
(1)  "Cost-sharing amount" includes an amount charged for a deductible, coinsurance, or copayment.
(2)  "Health care provider" means a person who provides health care services under a license, certificate, registration, or other similar evidence of regulation issued by this or another state of the United States.
(3)  "Physician" means an individual licensed to practice medicine in this or another state of the United States.
Added by Acts 2017, 85th Leg., R.S., Ch. 1007 (H.B. 1296), 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 J. Coverage Related to Prescription Drug Synchronization › Section 1369.452. Applicability of Subchapter

Sec. 1369.452.  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; or
(8)  an exchange operating under Chapter 942.
(b)  This subchapter applies to group health coverage made available by a school district in accordance with Section 22.004, Education Code.
(c)  Notwithstanding any provision in Chapter 1551, 1575, 1579, or 1601 or any other law, this subchapter applies to health benefit plan coverage provided under:
(1)  Chapter 1551;
(2)  Chapter 1575;
(3)  Chapter 1579; and
(4)  Chapter 1601.
(d)  Notwithstanding Section 1501.251 or any other law, this subchapter applies to coverage under a small employer health benefit plan subject to Chapter 1501.
(e)  This subchapter applies to a standard health benefit plan issued under Chapter 1507.
Text of subsection effective until April 01, 2025
(f)  To the extent allowed by federal law, the child health plan program operated under Chapter 62, Health and Safety Code, and the state Medicaid program, including the Medicaid managed care program operated under Chapter 533, Government Code, shall provide the coverage required under this subchapter to a recipient.
Text of subsection effective on April 01, 2025
(f)  To the extent allowed by federal law, the child health plan program operated under Chapter 62, Health and Safety Code, and the state Medicaid program, including the Medicaid managed care program operated under Chapters 540 and 540A, Government Code, shall provide the coverage required under this subchapter to a recipient.
Added by Acts 2017, 85th Leg., R.S., Ch. 1007 (H.B. 1296), Sec. 1, eff. September 1, 2017.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.128, 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 J. Coverage Related to Prescription Drug Synchronization › Section 1369.453. Applicability to Certain Medications

Sec. 1369.453.  APPLICABILITY TO CERTAIN MEDICATIONS.  This subchapter applies with respect to only a medication that:
(1)  is covered by the enrollee's health benefit plan;
(2)  meets the prior authorization criteria specifically applicable to the medication under the health benefit plan on the date the request for synchronization is made;
(3)  is used for treatment and management of a chronic illness, as that term is defined by Section 1369.456;
(4)  may be prescribed with refills;
(5)  is a formulation that can be effectively dispensed in accordance with the medication synchronization plan described by Section 1369.456; and
(6)  is not, according to the schedules established by the commissioner of the Department of State Health Services under Chapter 481, Health and Safety Code:
(A)  a Schedule II controlled substance; or
(B)  a Schedule III controlled substance containing hydrocodone.
Added by Acts 2017, 85th Leg., R.S., Ch. 1007 (H.B. 1296), 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 J. Coverage Related to Prescription Drug Synchronization › Section 1369.454. Proration of Cost-Sharing Amount Required

Sec. 1369.454.  PRORATION OF COST-SHARING AMOUNT REQUIRED.  (a)  A health benefit plan that provides benefits for prescription drugs shall prorate any cost-sharing amount charged for a partial supply of a prescription drug if:
(1)  the pharmacy or the enrollee's prescribing physician or health care provider notifies the health benefit plan that:
(A)  the quantity dispensed is to synchronize the dates that the pharmacy dispenses the enrollee's prescription drugs; and
(B)  the synchronization of the dates is in the best interest of the enrollee; and
(2)  the enrollee agrees to the synchronization.
(b)  The proration described by Subsection (a) must be based on the number of days' supply of the drug actually dispensed.
Added by Acts 2017, 85th Leg., R.S., Ch. 1007 (H.B. 1296), 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 J. Coverage Related to Prescription Drug Synchronization › Section 1369.455. Proration of Dispensing Fee Prohibited

Sec. 1369.455.  PRORATION OF DISPENSING FEE PROHIBITED.  A health benefit plan that prorates a cost-sharing amount as required by Section 1369.454 may not prorate the fee paid to the pharmacy for dispensing the drug for which the cost-sharing amount was prorated.
Added by Acts 2017, 85th Leg., R.S., Ch. 1007 (H.B. 1296), 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 J. Coverage Related to Prescription Drug Synchronization › Section 1369.456. Implementation of Certain Medication Synchronization Plans

Sec. 1369.456.  IMPLEMENTATION OF CERTAIN MEDICATION SYNCHRONIZATION PLANS.  (a)  For the purposes of this section:
(1)  "Chronic illness" means an illness or physical condition that may be:
(A)  reasonably expected to continue for an uninterrupted period of at least three months; and
(B)  controlled but not cured by medical treatment.
(2)  "Medication synchronization plan" means a plan established for the purpose of synchronizing the filling or refilling of multiple prescriptions.
(b)  A health benefit plan shall establish a process through which the following parties may jointly approve a medication synchronization plan for medication to treat an enrollee's chronic illness:
(1)  the health benefit plan;
(2)  the enrollee;
(3)  the prescribing physician or health care provider; and
(4)  a pharmacist.
(c)  A health benefit plan shall provide coverage for a medication dispensed in accordance with the dates established in the medication synchronization plan described by Subsection (b).
(d)  A health benefit plan shall establish a process that allows a pharmacist or pharmacy to override the health benefit plan's denial of coverage for a medication described by Subsection (b).
(e)  A health benefit plan shall allow a pharmacist or pharmacy to override the health benefit plan's denial of coverage through the process described by Subsection (d), and the health benefit plan shall provide coverage for the medication if:
(1)  the prescription for the medication is being refilled in accordance with the medication synchronization plan described by Subsection (b); and
(2)  the reason for the denial is that the prescription is being refilled before the date established by the plan's general prescription refill guidelines.
Added by Acts 2017, 85th Leg., R.S., Ch. 1007 (H.B. 1296), 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 K. Prescription Drug Cost Transparency › Section 1369.501. Definitions

Sec. 1369.501.  DEFINITIONS.  In this subchapter:
(1)  "Animal health product" means a medical product approved and licensed for use in animal or veterinary medicine, including  a pharmaceutical, a biologic, an insecticide, and a parasiticide.
(2)  "Health benefit plan" means an individual, blanket, or group plan, policy, or contract for health care services issued or delivered by a health benefit plan issuer in this state.
(3)  "Health benefit plan issuer" means an insurance company, a health maintenance organization, or a hospital and medical service corporation.
(4)  "Pharmaceutical drug manufacturer" means a person engaged in the business of producing, preparing, propagating, compounding, converting, processing, packaging, labeling, or distributing a prescription drug.  The term does not include a wholesale distributor or retailer of prescription drugs or a pharmacist licensed under Subtitle J, Title 3, Occupations Code.
(5)  "Pharmacy benefit manager" has the meaning assigned by Section 4151.151.
(6)  "Prescription drug" has the meaning assigned by Section 551.003, Occupations Code, except that the term "prescription drug" does not include a device or an animal health product.
(7)  "Rebate" means a discount or concession that affects the price of a prescription drug to a pharmacy benefit manager or health benefit plan issuer for a prescription drug manufactured by the pharmaceutical drug manufacturer.
(8)  "Specialty drug" means a prescription drug covered under Medicare Part D that exceeds the specialty tier cost threshold established by the Centers for Medicare and Medicaid Services.
(9)  "Utilization management" means a set of formal techniques designed to monitor the use of, or evaluate the medical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures, or settings.
Added by Acts 2019, 86th Leg., R.S., Ch. 1291 (H.B. 2536), Sec. 2, eff. September 1, 2019.