Sec. 1369.056. ADVERSE DETERMINATION. (a) The refusal of a 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 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 (H.B. 2636), Sec. 2G.012, eff. April 1, 2009.
Acts 2011, 82nd Leg., R.S., Ch. 501 (H.B. 1405), Sec. 7, eff. September 1, 2011.
Structure Texas Statutes
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 B. Coverage of Prescription Drugs Specified by Drug Formulary
Section 1369.052. Applicability of Subchapter
Section 1369.054. Notice and Disclosure of Certain Information Required
Section 1369.0541. Modification of Drug Coverage Under Plan
Section 1369.0545. Step Therapy Protocols
Section 1369.0546. Step Therapy Protocol Exception Requests
Section 1369.055. Continuation of Coverage Required; Other Drugs Not Precluded