Title IN, Insurance Code

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…

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…

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…

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…

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 indiv…

Sec. 1369.502. PHARMACY BENEFIT MANAGER INFORMATION. (a) Not later than March 1 of each year, each pharmacy benefit manager shall file a report with the commissioner. The report must state for the immediately preceding calendar year: (1) the aggregated rebates, fees, price protec…

Sec. 1369.503. HEALTH BENEFIT PLAN ISSUER INFORMATION. (a) Not later than March 1 of each year, each health benefit plan issuer shall submit to the commissioner a report that states for the immediately preceding calendar year: (1) the names of the 25 most frequently prescribed pr…

Sec. 1369.5035. CONTENT OF REPORTS. The reports required by Sections 1369.502 and 1369.503 must include information relating to private health benefit plans that cover prescription drugs and are regulated by the department. The reports may not include information relating to: (1)…

Sec. 1369.504. RULES. The commissioner may adopt rules to implement this subchapter. Added by Acts 2019, 86th Leg., R.S., Ch. 1291 (H.B. 2536), Sec. 2, eff. September 1, 2019. SUBCHAPTER L. AFFILIATED PROVIDERS

Sec. 1369.551. DEFINITIONS. In this subchapter: (1) "Affiliated provider" means a pharmacy or durable medical equipment provider that directly, or indirectly through one or more intermediaries, controls, is controlled by, or is under common control with a health benefit plan issu…

Sec. 1369.552. EXCEPTIONS TO APPLICABILITY OF SUBCHAPTER. Notwithstanding the definition of "health benefit plan" provided by Section 1369.551, this subchapter does not apply to an issuer or provider of health benefits under or a pharmacy benefit manager administering pharmacy be…

Sec. 1369.553. TRANSFER OR ACCEPTANCE OF CERTAIN RECORDS PROHIBITED. (a) In this section, "commercial purpose" does not include pharmacy reimbursement, formulary compliance, pharmaceutical care, utilization review by a health care provider, or a public health activity authorized …

Sec. 1369.554. PROHIBITION ON CERTAIN COMMUNICATIONS. (a) A health benefit plan issuer or pharmacy benefit manager may not steer or direct a patient to use the issuer's or manager's affiliated provider through any oral or written communication, including: (1) online messaging reg…

Sec. 1369.555. PROHIBITION ON CERTAIN REFERRALS AND SOLICITATIONS. (a) A health benefit plan issuer or pharmacy benefit manager may not require a patient to use the issuer's or manager's affiliated provider in order for the patient to receive the maximum benefit for the service u…

Sec. 1369.601. DEFINITIONS. In this subchapter: (1) "Pharmacy benefit manager" has the meaning assigned by Section 4151.151. (2) "Pharmacy benefit network" means a network of pharmacies that have contracted with a pharmacy benefit manager to provide pharmacist services to enrolle…

Sec. 1369.602. 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 i…

Sec. 1369.6021. ONLINE ACCESS TO PHARMACY BENEFIT NETWORK CONTRACT. A health benefit plan issuer or pharmacy benefit manager shall make available to any pharmacist or pharmacy in the issuer's or manager's pharmacy benefit network access to a secure, online portal through which th…

Sec. 1369.6022. PHARMACY BENEFIT NETWORK CONTRACT: ADVERSE MATERIAL CHANGES. (a) In this section, "adverse material change" means a modification or addendum to a pharmacy benefit network contract that would decrease a pharmacist's or pharmacy's payment or compensation, change the…

Sec. 1369.6023. PHARMACY BENEFIT NETWORK CONTRACT: OTHER MODIFICATIONS AND ADDENDUMS. (a) A health benefit plan issuer or pharmacy benefit manager must, not later than the 90th day before the date a proposed modification or addendum to a pharmacy benefit network contract, other t…

Sec. 1369.6024. PHARMACY BENEFIT NETWORK CONTRACT DISCLOSURE. A pharmacy benefit network contract must state that the contract is subject to this chapter and any rules adopted by the commissioner under this chapter. Added by Acts 2025, 89th Leg., R.S., Ch. 183 (S.B. 1236), Sec. 4…

Sec. 1369.6025. PROVIDER MANUAL DISCLOSURE. A health benefit plan issuer or pharmacy benefit manager shall: (1) make a provider manual readily available on the online portal described by Section 1369.6021; and (2) post a modification or addendum to the provider manual to the onli…

Sec. 1369.6026. PHARMACY BENEFIT NETWORK CONTRACT FEE LIMITATIONS. A health benefit plan issuer or pharmacy benefit manager may not charge a fee, including an application or participation fee, before providing a pharmacist or pharmacy with the full proposed pharmacy benefit netwo…

Sec. 1369.6027. PHARMACY BENEFIT NETWORK PARTICIPATION REQUIREMENTS PROHIBITED. A health benefit plan issuer or pharmacy benefit manager may not: (1) require a pharmacist or pharmacy to participate in a pharmacy benefit network; (2) condition a pharmacist's or pharmacy's particip…

Sec. 1369.603. REDUCTION OF CERTAIN CLAIM PAYMENT AMOUNTS PROHIBITED. (a) A health benefit plan issuer or pharmacy benefit manager may not directly or indirectly reduce the amount of a claim payment to a pharmacist or pharmacy after adjudication of the claim through the use of an…

Sec. 1369.604. REIMBURSEMENT OF AFFILIATED AND NONAFFILIATED PHARMACISTS AND PHARMACIES. (a) In this section: (1) "Affiliated pharmacist or pharmacy" means a pharmacist or pharmacy that directly, or indirectly through one or more intermediaries, controls or is controlled by, or i…

Sec. 1369.605. NETWORK CONTRACT FEE SCHEDULE. A pharmacy benefit network contract must include a fee schedule. The fee schedule must describe: (1) specific services or procedures that the pharmacist or pharmacy may deliver and the amount of the corresponding payment; (2) a method…

Sec. 1369.606. DISCLOSURE OF PHARMACY SERVICES ADMINISTRATIVE ORGANIZATION CONTRACT. A pharmacist or pharmacy that is a member of a pharmacy services administrative organization that enters into a contract with a health benefit plan issuer or pharmacy benefit manager on the pharm…

Sec. 1369.607. DELIVERY OF DRUGS. (a) Except in a case in which the health benefit plan issuer or pharmacy benefit manager makes a credible allegation of fraud against the pharmacist or pharmacy and provides reasonable notice of the allegation and the basis of the allegation to t…

Sec. 1369.608. PROFESSIONAL STANDARDS AND SCOPE OF PRACTICE REQUIREMENTS. A health benefit plan issuer or pharmacy benefit manager may not as a condition of a contract with a pharmacist or pharmacy: (1) require pharmacist or pharmacy accreditation standards or recertification req…

Sec. 1369.609. RETALIATION PROHIBITED. (a) A pharmacy benefit manager may not retaliate against a pharmacist or pharmacy based on the pharmacist's or pharmacy's exercise of any right or remedy under this chapter. Retaliation prohibited by this section includes: (1) terminating or…

Sec. 1369.610. WAIVER PROHIBITED. The provisions of this subchapter may not be waived, voided, or nullified by contract. Added by Acts 2021, 87th Leg., R.S., Ch. 142 (H.B. 1763), Sec. 1, eff. September 1, 2021. Redesignated from Insurance Code, Section 1369.560 by Acts 2023, 88th…

Sec. 1369.651. DEFINITION. In this subchapter, "prescription drug" has the meaning assigned by Section 551.003, Occupations Code. Added by Acts 2023, 88th Leg., R.S., Ch. 669 (H.B. 755), Sec. 1, eff. September 1, 2023.

Sec. 1369.652. APPLICABILITY OF SUBCHAPTER. (a) This subchapter applies only to a health benefit plan that provides benefits for medical, surgical, or prescription drug expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, bla…

Sec. 1369.653. EXCEPTIONS. (a) 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; or (B) only for hospital expenses; (2) the stat…

Sec. 1369.654. PROHIBITION ON MULTIPLE PRIOR AUTHORIZATIONS. (a) A health benefit plan issuer that provides prescription drug benefits may not require an enrollee to receive more than one prior authorization annually of the prescription drug benefit for a prescription drug prescr…

Sec. 1369.761. DEFINITIONS. In this subchapter: (1) "Administer" means to directly apply a drug to the body of a patient by injection, inhalation, ingestion, or any other means. (2) "Clinician-administered drug" means an outpatient prescription drug other than a vaccine that: (A)…

Sec. 1369.762. 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 i…

Sec. 1369.763. EXCEPTIONS TO APPLICABILITY OF SUBCHAPTER. (a) This subchapter does not apply to an issuer or provider of health benefits under or a pharmacy benefit manager administering pharmacy benefits under: (1) the state Medicaid program, including the Medicaid managed care …

Sec. 1369.764. CERTAIN LIMITATIONS ON COVERAGE OF CLINICIAN-ADMINISTERED DRUGS PROHIBITED. (a) Subject to Subsection (b), a health benefit plan issuer may not, for an enrollee with a chronic, complex, rare, or life-threatening medical condition: (1) require clinician-administered…

Sec. 1370.001. APPLICABILITY OF CHAPTER. (a) This chapter 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 insuran…

Sec. 1370.002. EXCEPTIONS. (a) This chapter does not apply to: (1) a plan that provides coverage: (A) only for benefits for a specified disease or for another limited benefit, other than a plan that provides benefits for cancer treatment or similar services; (B) only for accident…

Sec. 1370.003. COVERAGE REQUIRED. (a) A health benefit plan that provides coverage for diagnostic medical procedures must provide to each woman 18 years of age or older enrolled in the plan coverage for expenses for an annual medically recognized diagnostic examination for the ea…

Sec. 1370.004. NOTICE OF COVERAGE. (a) A health benefit plan issuer shall provide to each woman 18 years of age or older enrolled in the plan written notice of the coverage required under this chapter. (b) The notice must be provided in accordance with rules adopted by the commis…

Sec. 1371.001. DEFINITIONS. In this chapter: (1) "Enrollee" means an individual entitled to coverage under a health benefit plan. (2) "Orthotic device" means a custom-fitted or custom-fabricated medical device that is applied to a part of the human body to correct a deformity, im…

Sec. 1371.002. APPLICABILITY OF CHAPTER. (a) This chapter applies only to a health benefit plan, including a small employer health benefit plan written under Chapter 1501 or coverage provided by a health group cooperative under Subchapter B of that chapter, that provides benefits…

Sec. 1371.003. REQUIRED COVERAGE FOR PROSTHETIC DEVICES, ORTHOTIC DEVICES, AND RELATED SERVICES. (a) A health benefit plan must provide coverage for prosthetic devices, orthotic devices, and professional services related to the fitting and use of those devices that equals the cov…