Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter V - PHARMACY BENEFITS › Division 4 - PRESCRIPTION DRUG FORMULARY COVERAGE AND DISCLOSURE REQUIREMENTS › Section 21.3033 - Facilitating Comparison Shopping for Individual Health Benefit Plans

Current through Reg. 49, No. 28; July 12, 2024
(a) The formulary information required by
					 §
											21.3032
					 of this title (relating to Formulary Disclosure Requirements for Individual
					 Health Benefit Plans) must include a summary titled "Summary of Formulary
					 Benefits" that includes this statement: "The information in this document is
					 designed to help you understand the prescription drug benefits offered under
					 this plan and to compare these benefits to those offered by other plans.
					 Information contained in this summary is designed to help you compare both the
					 value and scope of formulary benefits." The summary must also include, in the
					 following order:
(1) Under the header, "How
					 to Find Information on the Cost of Prescription Drugs," a description of how a
					 consumer may use the plan's summary health plan document, formulary
					 information, and web-based tool, if applicable, to determine the cost sharing
					 they may owe, and an explanation that cost-sharing information reflects a
					 consumer's share of the cost excluding any deductible requirement, calculated
					 using an estimate of the full price of the drug, which is based on the plan's
					 median or the actual cost allowed amount at a given point in time.
(2) Under the header, "Formulary by Health
					 Benefit Plan," a chart that displays each formulary that applies to each
					 individual health benefit plan issued by the issuer and includes a direct
					 electronic link to the Summary of Benefits and Coverage for each individual
					 health plan listed. This chart may be limited to individual health benefit
					 plans being sold in the market in which the applicable health benefit plan is
					 issued.
(3) Under the header,
					 "Drugs by Cost-Sharing Tier," if the drug formulary is a multitier formulary, a
					 summary that displays the percent of drugs in each cost-sharing tier for all
					 drugs in the formulary.
(4) Under
					 the header, "How Prescription Drugs are Covered under the Plan":
(A) under a section titled, "Formulary
					 Composition," an explanation of the method the issuer uses to determine the
					 prescription drugs to be included in or excluded from the formulary, an
					 explanation of whether the formulary is open or closed, and a statement of how
					 often the issuer reviews the contents of the formulary.
(B) Under a section titled, "Right to
					 Appeal," an explanation that if a drug is not covered under the formulary, but
					 the enrollee's physician has determined that the drug is medically necessary,
					 the consumer has the right to appeal, consistent with §
													21.3023
					 of this title (relating to Nonformulary Prescription Drugs; Adverse
					 Determination) and Insurance Code §
													1369.056. A
					 statement of how cost sharing will be determined for drugs covered as a result
					 of a successful appeal.
(C) Under a
					 section titled, "Continuation of Coverage," an explanation of a consumer's
					 right to continued coverage for a prescription drug at the coverage level or
					 tier at which the drug was covered at the beginning of the plan year, until the
					 enrollee's plan renewal date, consistent with §
													21.3022
					 of this title (relating to Continuation of Benefits) and Insurance Code §
													1369.055
					 and § 1369.0541.
(D) Under a
					 section titled, "Off-Label Drug Use," an explanation of how formulary drugs are
					 covered under the plan, including an explanation of coverage for off-label drug
					 use.
(E) Under a section titled,
					 "Cost Sharing," an explanation of how cost sharing is determined under the
					 plan, including whether a deductible applies to prescription drug coverage; how
					 cost sharing for prescription drugs counts towards the plan's deductible; how
					 drugs are categorized into each of the formulary tiers or cost-sharing levels,
					 whether the drug formulary is a multitier formulary; the difference between
					 preferred and nonpreferred drugs, if applicable; the difference in coverage for
					 drugs dispensed from in-network and out-of-network pharmacies; and the
					 difference in coverage for drugs dispensed in a retail pharmacy and a
					 mail-order pharmacy, if applicable.
(F) Under a section titled, "Medical
					 Management Requirements," an explanation of each type of medical management
					 requirement used by the individual health benefit plan, including prior
					 authorization, step therapy, or other protocol requirements that limit access
					 to prescription drugs, as applicable.