Law:Title 8. Health Insurance And Other Health Coverages. Subtitle E. Benefits Payable Under Health Coverages from Chapter 1369. Benefits Related To Prescription Drugs And Devices And Related Services (Texas)

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Subtitle E. Benefits Payable Under Health Coverages

Contents

Chapter 1369. Benefits Related To Prescription Drugs And Devices And Related Services

Subchapter A. Coverage Of Prescription Drugs In General

Section  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.

(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.



Section  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.



Section  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.



Section  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.



Section  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.



Subchapter B. Coverage Of Prescription Drugs Specified By Drug Formulary

Section  1369.051.  Definitions.

In this subchapter:

(1)  "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 group 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.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1369.052.

  APPLICABILITY OF

Subchapter

. This subchapter applies only to a group health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including a group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or a 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.



Section  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 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 1369.052.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1369.054.  Notice And Disclosure Of Certain Information Required.

An issuer of a group 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.



Section  1369.055.  Continuation Of Coverage Required; Other Drugs Not Precluded.

(a) An issuer of a group 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 group health benefit plan; and

(2)  medically appropriate for the enrollee.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section 1369.056.  Adverse Determination.

(a) The refusal of a group 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 group 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, Sec. 2G.012, eff. April 1, 2009.



Section  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.



Subchapter C. Coverage Of Prescription Contraceptive Drugs And Devices And Related Services

Section  1369.101.  Definitions.

In this subchapter:

(1)  "Enrollee" means a person who is entitled to benefits under a health benefit plan.

(2)  "Outpatient contraceptive service" means a consultation, examination, procedure, or medical service that is provided on an outpatient basis and that is related to the use of a drug or device intended to prevent pregnancy.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1369.102.

  APPLICABILITY OF

Subchapter

. This subchapter applies only to a health benefit plan, including a small employer health benefit plan written under Chapter 1501, that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage or similar coverage document that is offered by:

(1)  an insurance company;

(2)  a group hospital service corporation operating under Chapter 842;

(3)  a fraternal benefit society operating under Chapter 885;

(4)  a stipulated premium company operating under Chapter 884;

(5)  a reciprocal exchange operating under Chapter 942;

(6)  a health maintenance organization operating under Chapter 843;

(7)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846; or

(8)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1369.103.  Exception.

This subchapter does not apply to:

(1)  a health benefit plan that provides coverage only:

(A)  for a specified disease or for another limited benefit other than for cancer;

(B)  for accidental death or dismemberment;

(C)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury;

(D)  as a supplement to a liability insurance policy;

(E)  for credit insurance;

(F)  for dental or vision care; or

(G)  for indemnity for hospital confinement;

(2)  a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss), as amended;

(3)  a workers' compensation insurance policy;

(4)  medical payment insurance coverage provided under a motor vehicle insurance policy; or

(5)  a long-term care insurance policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Section 1369.102.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1369.104.  Exclusion Or Limitation Prohibited.

(a) A health benefit plan that provides benefits for prescription drugs or devices may not exclude or limit benefits to enrollees for:

(1)  a prescription contraceptive drug or device approved by the United States Food and Drug Administration; or

(2)  an outpatient contraceptive service.

(b)  This section does not prohibit a limitation that applies to all prescription drugs or devices or all services for which benefits are provided under a health benefit plan.

(c)  This section does not require a health benefit plan to cover abortifacients or any other drug or device that terminates a pregnancy.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1369.105.  Certain Cost-sharing Provisions Prohibited.

(a) A health benefit plan may not impose a deductible, copayment, coinsurance, or other cost-sharing provision applicable to benefits for prescription contraceptive drugs or devices unless the amount of the required cost-sharing is the same as or less than the amount of the required cost-sharing applicable to benefits for other prescription drugs or devices under the plan.

(b)  A health benefit plan may not impose a deductible, copayment, coinsurance, or other cost-sharing provision applicable to benefits for outpatient contraceptive services unless the amount of the required cost-sharing is the same as or less than the amount of the required cost-sharing applicable to benefits for other outpatient services under the plan.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1369.106.  Certain Waiting Periods Prohibited.

(a) A health benefit plan may not impose a waiting period applicable to benefits for prescription contraceptive drugs or devices unless the waiting period is the same as or shorter than any waiting period applicable to benefits for other prescription drugs or devices under the plan.

(b)  A health benefit plan may not impose a waiting period applicable to benefits for outpatient contraceptive services unless the waiting period is the same as or shorter than any waiting period applicable to benefits for other outpatient services under the plan.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1369.107.  Prohibited Conduct.

A health benefit plan issuer may not:

(1)  solely because of the applicant's or enrollee's use or potential use of a prescription contraceptive drug or device or an outpatient contraceptive service, deny:

(A)  the eligibility of an applicant to enroll in the plan;

(B)  the continued eligibility of an enrollee for coverage under the plan; or

(C)  the eligibility of an enrollee to renew coverage under the plan;

(2)  provide a monetary incentive to an applicant for enrollment or an enrollee to induce the applicant or enrollee to accept coverage that does not satisfy the requirements of this subchapter; or

(3)  reduce or limit a payment to a health care professional, or otherwise penalize the professional, because the professional prescribes a contraceptive drug or device or provides an outpatient contraceptive service.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1369.108.  Exemption For Entities Associated With Religious Organization.

(a) This subchapter does not require a health benefit plan that is issued by an entity associated with a religious organization or any physician or health care provider providing medical or health care services under the plan to offer, recommend, offer advice concerning, pay for, provide, assist in, perform, arrange, or participate in providing or performing a medical or health care service that violates the religious convictions of the organization, unless the prescription contraceptive coverage is necessary to preserve the life or health of the enrollee.

(b)  An issuer of a health benefit plan that excludes or limits coverage for medical or health care services under this section shall state the exclusion or limitation in:

(1)  the plan's coverage document;

(2)  the plan's statement of benefits;

(3)  plan brochures; and

(4)  other informational materials for the plan.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1369.109.  Enforcement.

A health benefit plan issuer that violates this subchapter is subject to the enforcement provisions of Subtitle B, Title 2.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Subchapter D. Pharmacy Benefit Cards

Section 1369.151.

  APPLICABILITY OF

Subchapter

. (a) This subchapter applies only to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage or similar coverage document that is offered by:

(1)  an insurance company;

(2)  a group hospital service corporation operating under Chapter 842;

(3)  a fraternal benefit society operating under Chapter 885;

(4)  a stipulated premium company operating under Chapter 884;

(5)  a reciprocal exchange operating under Chapter 942;

(6)  a health maintenance organization operating under Chapter 843;

(7)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846; or

(8)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844.

(b)  Notwithstanding any other law, this subchapter applies to coverage under:

(1)  the basic coverage plan under Chapter 1551;

(2)  the basic plan under Chapter 1575;

(3)  the primary care coverage plan under Chapter 1579;

(4)  the basic coverage plan under Chapter 1601;

(5)  the child health plan program under Chapter 62, Health and Safety Code; and

(6)  the medical assistance program under Chapter 32, Human Resources Code.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.

Amended by:

Acts 2009, 81st Leg., R.S., Ch. 1117, Sec. 1, eff. September 1, 2009.



Section  1369.152.  Exception.

This subchapter does not apply to:

(1)  a health benefit plan that provides coverage:

(A)  only for a specified disease or for another limited benefit;

(B)  only for accidental death or dismemberment;

(C)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury;

(D)  as a supplement to a liability insurance policy;

(E)  for credit insurance;

(F)  only for dental or vision care;

(G)  only for hospital expenses; or

(H)  only for indemnity for hospital confinement;

(2)  a small employer health benefit plan written under Chapter 1501;

(3)  a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);

(4)  a workers' compensation insurance policy;

(5)  medical payment insurance coverage provided under a motor vehicle insurance policy; or

(6)  a long-term care insurance policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Section 1369.151.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section 1369.153.  Information Required On Identification Card.

(a) An issuer of a health benefit plan that provides pharmacy benefits to enrollees shall include on the front of the identification card of each enrollee:

(1)  the name of the entity administering the pharmacy benefits if the entity is different from the health benefit plan issuer;

(2)  the group number applicable to the enrollee;

(3)  the identification number of the enrollee, which may not be the enrollee's social security number;

(4)  the bank identification number necessary for electronic billing;

(5)  the effective date of the coverage evidenced by the card; and

(6)  copayment information for generic and brand-name prescription drugs.

(b)  In addition to the information required under Subsection (a), the issuer of a health benefit plan shall include on the identification card of each enrollee:

(1)  the logo of the entity administering the pharmacy benefits if the entity is different from the health benefit plan issuer; and

(2)  a telephone number for contacting an appropriate person to obtain information relating to the pharmacy benefits provided under the plan.

(c)  In addition to complying with Subsections (a) and (b), an issuer of a health benefit plan may provide the information required under Subsections (a) and (b) in electronically readable form on the back of the identification card.

(d)  This section does not require a health benefit plan issuer that administers its own pharmacy benefits to issue an identification card separate from any identification card issued to an enrollee to evidence coverage under the plan if the identification card issued to evidence coverage contains the information required by Subsections (a) and (b).

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.

Amended by:

Acts 2009, 81st Leg., R.S., Ch. 1117, Sec. 2, eff. September 1, 2009.



Section 1369.154.  Rules.

(a) The commissioner shall adopt rules as necessary to implement this subchapter.

(b)  Rules adopted by the commissioner must be consistent with national standards established by the Workgroup for Electronic Data Interchange or by other similar organizations recognized by the commissioner.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.

Amended by:

Acts 2009, 81st Leg., R.S., Ch. 1117, Sec. 3, eff. September 1, 2009.


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