Texas Statutes
Subtitle E - Benefits Payable Under Health Coverages
Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services

Section 1369.055. Continuation of Coverage Required; Other Drugs Not Precluded - Sec. 1369.055. CONTINUATION OF COVERAGE REQUIRED; OTHER DRUGS NOT PRECLUDED....

Section 1369.056. Adverse Determination - Sec. 1369.056. ADVERSE DETERMINATION. (a) The refusal of a health...

Section 1369.057. Rules - Sec. 1369.057. RULES. The commissioner may adopt rules to implement...

Subchapter B. -1. Transparency Requirements for Certain Individual Health Benefit Plans

Section 1369.076. Definitions - Sec. 1369.076. DEFINITIONS. In this subchapter, terms defined by Subchapter...

Section 1369.077. Applicability of Subchapter - Sec. 1369.077. APPLICABILITY OF SUBCHAPTER. This subchapter applies only to...

Section 1369.078. Formulary Information on Internet Website - Sec. 1369.078. FORMULARY INFORMATION ON INTERNET WEBSITE. (a) A health...

Section 1369.079. Formulary Disclosure Requirements - Sec. 1369.079. FORMULARY DISCLOSURE REQUIREMENTS. (a) The commissioner shall develop...

Section 1369.080. Formulary Information Provided by Toll-Free Telephone Number - Sec. 1369.080. FORMULARY INFORMATION PROVIDED BY TOLL-FREE TELEPHONE NUMBER. In...

Subchapter C. Coverage of Prescription Contraceptive Drugs and Devices and Related Services

Section 1369.101. Definitions - Sec. 1369.101. DEFINITIONS. In this subchapter: (1) "Enrollee" means a...

Section 1369.102. Applicability of Subchapter - Sec. 1369.102. APPLICABILITY OF SUBCHAPTER. This subchapter applies only to...

Section 1369.103. Exception - Sec. 1369.103. EXCEPTION. This subchapter does not apply to: (1)...

Section 1369.104. Exclusion or Limitation Prohibited - Sec. 1369.104. EXCLUSION OR LIMITATION PROHIBITED. (a) A health benefit...

Section 1369.105. Certain Cost-Sharing Provisions Prohibited - Sec. 1369.105. CERTAIN COST-SHARING PROVISIONS PROHIBITED. (a) A health benefit...

Section 1369.106. Certain Waiting Periods Prohibited - Sec. 1369.106. CERTAIN WAITING PERIODS PROHIBITED. (a) A health benefit...

Section 1369.107. Prohibited Conduct - Sec. 1369.107. PROHIBITED CONDUCT. A health benefit plan issuer may...

Section 1369.108. Exemption for Entities Associated With Religious Organization - Sec. 1369.108. EXEMPTION FOR ENTITIES ASSOCIATED WITH RELIGIOUS ORGANIZATION. (a)...

Section 1369.109. Enforcement - Sec. 1369.109. ENFORCEMENT. A health benefit plan issuer that violates...

Subchapter D. Pharmacy Benefit Cards

Section 1369.151. Applicability of Subchapter - Sec. 1369.151. APPLICABILITY OF SUBCHAPTER. (a) This subchapter applies only...

Section 1369.152. Exception - Sec. 1369.152. EXCEPTION. This subchapter does not apply to: (1)...

Section 1369.153. Information Required on Identification Card - Sec. 1369.153. INFORMATION REQUIRED ON IDENTIFICATION CARD. (a) An issuer...

Section 1369.154. Rules - Sec. 1369.154. RULES. (a) The commissioner shall adopt rules as...

Subchapter E. Coverage for Orally Administered Anticancer Medications

Section 1369.201. Definitions - Sec. 1369.201. DEFINITIONS. In this subchapter: (1) "Health benefit exchange"...

Section 1369.202. Applicability of Subchapter - Sec. 1369.202. APPLICABILITY OF SUBCHAPTER. This subchapter applies only to...

Section 1369.203. Exception - Sec. 1369.203. EXCEPTION. (a) This subchapter does not apply to:...

Section 1369.204. Required Coverage for Orally Administered Anticancer Medications - Sec. 1369.204. REQUIRED COVERAGE FOR ORALLY ADMINISTERED ANTICANCER MEDICATIONS. (a)...

Subchapter E. -1. Coverage of Prescription Drugs for Stage-Four Advanced, Metastatic Cancer

Section 1369.211. Definitions - Sec. 1369.211. DEFINITIONS. In this subchapter: (1) "Associated conditions" means...

Section 1369.212. Applicability of Subchapter - Sec. 1369.212. APPLICABILITY OF SUBCHAPTER. (a) This subchapter applies only...

Section 1369.213. Prohibited Conduct - Sec. 1369.213. PROHIBITED CONDUCT. (a) A health benefit plan that...

Subchapter F. Audits of Pharmacists and Pharmacies

Section 1369.251. Definitions - Sec. 1369.251. DEFINITIONS. In this subchapter: (1) "Desk audit" means...

Section 1369.252. Exceptions to Applicability of Subchapter - Sec. 1369.252. EXCEPTIONS TO APPLICABILITY OF SUBCHAPTER. This subchapter does...

Section 1369.253. Conflict With Other Laws - Sec. 1369.253. CONFLICT WITH OTHER LAWS. If there is a...

Section 1369.254. Audit of Pharmacist or Pharmacy; Notice; General Provisions - Sec. 1369.254. AUDIT OF PHARMACIST OR PHARMACY; NOTICE; GENERAL PROVISIONS....

Section 1369.255. Completion of Audit - Sec. 1369.255. COMPLETION OF AUDIT. An audit of a claim...

Section 1369.256. Audit Requiring Professional Judgment - Sec. 1369.256. AUDIT REQUIRING PROFESSIONAL JUDGMENT. A health benefit plan...

Section 1369.257. Access to Pharmacy Area - Sec. 1369.257. ACCESS TO PHARMACY AREA. A health benefit plan...

Section 1369.258. Validation Using Certain Records Authorized - Sec. 1369.258. VALIDATION USING CERTAIN RECORDS AUTHORIZED. A pharmacist or...

Section 1369.2581. Audit Discrepancies; Wholesale Invoices - Sec. 1369.2581. AUDIT DISCREPANCIES; WHOLESALE INVOICES. (a) A health benefit...

Section 1369.259. Calculation of Recoupment; Use of Extrapolation Prohibited - Sec. 1369.259. CALCULATION OF RECOUPMENT; USE OF EXTRAPOLATION PROHIBITED. (a)...

Section 1369.260. Clerical or Recordkeeping Error; Fraud Allegation - Sec. 1369.260. CLERICAL OR RECORDKEEPING ERROR; FRAUD ALLEGATION. (a) An...

Section 1369.261. Access to Previous Audit Reports; Uniform Audit Standards - Sec. 1369.261. ACCESS TO PREVIOUS AUDIT REPORTS; UNIFORM AUDIT STANDARDS....

Section 1369.262. Compensation of Auditor - Sec. 1369.262. COMPENSATION OF AUDITOR. An individual performing an on-site...

Section 1369.263. Conclusion of Audit; Summary; Preliminary Audit Report - Sec. 1369.263. CONCLUSION OF AUDIT; SUMMARY; PRELIMINARY AUDIT REPORT. (a)...

Section 1369.264. Final Audit Report - Sec. 1369.264. FINAL AUDIT REPORT. Not later than the 120th...

Section 1369.265. Certain Audits Exempt From Deadlines - Sec. 1369.265. CERTAIN AUDITS EXEMPT FROM DEADLINES. A health benefit...

Section 1369.266. Recoupment and Interest Charged After Audit - Sec. 1369.266. RECOUPMENT AND INTEREST CHARGED AFTER AUDIT. (a) If...

Section 1369.267. Waiver Prohibited - Sec. 1369.267. WAIVER PROHIBITED. The provisions of this subchapter may...

Section 1369.268. Remedies Not Exclusive - Sec. 1369.268. REMEDIES NOT EXCLUSIVE. This subchapter may not be...

Section 1369.269. Enforcement; Rules - Sec. 1369.269. ENFORCEMENT; RULES. The commissioner may enforce this subchapter...

Section 1369.270. Legislative Declaration - Sec. 1369.270. LEGISLATIVE DECLARATION. Except as provided by Section 1369.252,...

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...

Section 1369.302. Applicability of Subchapter - Sec. 1369.302. APPLICABILITY OF SUBCHAPTER. (a) This subchapter applies only...

Section 1369.303. Exception - Sec. 1369.303. EXCEPTION. This subchapter does not apply to: (1)...

Section 1369.304. Standard Form - Sec. 1369.304. STANDARD FORM. (a) The commissioner by rule shall:...

Section 1369.305. Advisory Committee on Uniform Prior Authorization Forms - Sec. 1369.305. ADVISORY COMMITTEE ON UNIFORM PRIOR AUTHORIZATION FORMS. (a)...

Section 1369.306. Failure to Use or Acknowledge Standard Form - Sec. 1369.306. FAILURE TO USE OR ACKNOWLEDGE STANDARD FORM. If...

Subchapter H. Maximum Allowable Cost

Section 1369.351. Definitions - Sec. 1369.351. DEFINITIONS. In this subchapter: (1) "Health benefit plan"...

Section 1369.352. Certain Benefits Excluded - Sec. 1369.352. CERTAIN BENEFITS EXCLUDED. This subchapter does not apply...

Section 1369.353. Criteria for Drugs on Maximum Allowable Cost Lists - Sec. 1369.353. CRITERIA FOR DRUGS ON MAXIMUM ALLOWABLE COST LISTS....

Section 1369.354. Formulation of Maximum Allowable Costs; Disclosures - Sec. 1369.354. FORMULATION OF MAXIMUM ALLOWABLE COSTS; DISCLOSURES. (a) In...

Section 1369.355. Updates - Sec. 1369.355. UPDATES. (a) A health benefit plan issuer or...

Section 1369.356. Access to Maximum Allowable Cost Lists - Sec. 1369.356. ACCESS TO MAXIMUM ALLOWABLE COST LISTS. A health...

Section 1369.357. Appeal From Maximum Allowable Cost Price Determination - Sec. 1369.357. APPEAL FROM MAXIMUM ALLOWABLE COST PRICE DETERMINATION. (a)...

Section 1369.358. Confidentiality of Maximum Allowable Cost List - Sec. 1369.358. CONFIDENTIALITY OF MAXIMUM ALLOWABLE COST LIST. A maximum...

Section 1369.359. Waiver Prohibited - Sec. 1369.359. WAIVER PROHIBITED. The provisions of this subchapter may...

Section 1369.360. Remedies Not Exclusive - Sec. 1369.360. REMEDIES NOT EXCLUSIVE. This subchapter may not be...

Section 1369.361. Enforcement - Sec. 1369.361. ENFORCEMENT. The commissioner shall enforce this subchapter. Added...

Section 1369.362. Legislative Declaration - Sec. 1369.362. LEGISLATIVE DECLARATION. It is the intent of the...

Subchapter I. Pharmacy Benefit Claim Adjudication

Section 1369.401. Definition - Sec. 1369.401. DEFINITION. In this subchapter, "pharmacy benefit manager" has...

Section 1369.402. Certain Fees Prohibited - Sec. 1369.402. CERTAIN FEES PROHIBITED. A health benefit plan issuer...

Subchapter J. Coverage Related to Prescription Drug Synchronization

Section 1369.451. Definitions - Sec. 1369.451. DEFINITIONS. In this subchapter: (1) "Cost-sharing amount" includes...

Section 1369.452. Applicability of Subchapter - Sec. 1369.452. APPLICABILITY OF SUBCHAPTER. (a) This subchapter applies only...

Section 1369.453. Applicability to Certain Medications - Sec. 1369.453. APPLICABILITY TO CERTAIN MEDICATIONS. This subchapter applies with...

Section 1369.454. Proration of Cost-Sharing Amount Required - Sec. 1369.454. PRORATION OF COST-SHARING AMOUNT REQUIRED. (a) A health...

Section 1369.455. Proration of Dispensing Fee Prohibited - Sec. 1369.455. PRORATION OF DISPENSING FEE PROHIBITED. A health benefit...

Section 1369.456. Implementation of Certain Medication Synchronization Plans - Sec. 1369.456. IMPLEMENTATION OF CERTAIN MEDICATION SYNCHRONIZATION PLANS. (a) For...

Subchapter K. Prescription Drug Cost Transparency

Section 1369.501. Definitions - Sec. 1369.501. DEFINITIONS. In this subchapter: (1) "Animal health product"...

Section 1369.502. Pharmacy Benefit Manager Information - Sec. 1369.502. PHARMACY BENEFIT MANAGER INFORMATION. (a) Not later than...

Section 1369.503. Health Benefit Plan Issuer Information - Sec. 1369.503. HEALTH BENEFIT PLAN ISSUER INFORMATION. (a) Not later...

Section 1369.5035. Content of Reports - Sec. 1369.5035. CONTENT OF REPORTS. The reports required by Sections...

Section 1369.504. Rules - Sec. 1369.504. RULES. The commissioner may adopt rules to implement...

Subchapter L. Contracts With Pharmacists and Pharmacies

Section 1369.551. Definitions - Sec. 1369.551. DEFINITIONS. In this subchapter: (1) "Pharmacy benefit manager"...

Section 1369.552. Applicability of Subchapter - Sec. 1369.552. APPLICABILITY OF SUBCHAPTER. (a) This subchapter applies only...

Section 1369.553. Reduction of Certain Claim Payment Amounts Prohibited - Sec. 1369.553. REDUCTION OF CERTAIN CLAIM PAYMENT AMOUNTS PROHIBITED. (a)...

Section 1369.554. Reimbursement of Affiliated and Nonaffiliated Pharmacists and Pharmacies - Sec. 1369.554. REIMBURSEMENT OF AFFILIATED AND NONAFFILIATED PHARMACISTS AND PHARMACIES....

Section 1369.555. Network Contract Fee Schedule - Sec. 1369.555. NETWORK CONTRACT FEE SCHEDULE. A pharmacy benefit network...

Section 1369.556. Disclosure of Pharmacy Services Administrative Organization Contract - Sec. 1369.556. DISCLOSURE OF PHARMACY SERVICES ADMINISTRATIVE ORGANIZATION CONTRACT. A...

Section 1369.557. Delivery of Drugs - Sec. 1369.557. DELIVERY OF DRUGS. (a) Except in a case...

Section 1369.558. Professional Standards and Scope of Practice Requirements - Sec. 1369.558. PROFESSIONAL STANDARDS AND SCOPE OF PRACTICE REQUIREMENTS. A...

Section 1369.559. Retaliation Prohibited - Sec. 1369.559. RETALIATION PROHIBITED. (a) A pharmacy benefit manager may...

Section 1369.560. Waiver Prohibited - Sec. 1369.560. WAIVER PROHIBITED. The provisions of this subchapter may...

Subchapter L. Affiliated Providers

Section 1369.551. Definitions - Sec. 1369.551. DEFINITIONS. In this subchapter: (1) "Affiliated provider" means...

Section 1369.552. Exceptions to Applicability of Subchapter - Sec. 1369.552. EXCEPTIONS TO APPLICABILITY OF SUBCHAPTER. Notwithstanding the definition...

Section 1369.553. Transfer or Acceptance of Certain Records Prohibited - Sec. 1369.553. TRANSFER OR ACCEPTANCE OF CERTAIN RECORDS PROHIBITED. (a)...

Section 1369.554. Prohibition on Certain Communications - Sec. 1369.554. PROHIBITION ON CERTAIN COMMUNICATIONS. (a) A health benefit...

Section 1369.555. Prohibition on Certain Referrals and Solicitations - Sec. 1369.555. PROHIBITION ON CERTAIN REFERRALS AND SOLICITATIONS. (a) A...

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Texas Statutes Subtitle E - Benefits Payable Under Health Coverages Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services

Texas Statutes
Subtitle E - Benefits Payable Under Health Coverages
Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services