Texas Statutes
Subchapter B. -1. Transparency Requirements for Certain Individual Health Benefit Plans
Section 1369.079. Formulary Disclosure Requirements

Sec. 1369.079. FORMULARY DISCLOSURE REQUIREMENTS. (a) The commissioner shall develop and adopt by rule requirements to promote consistency and clarity in the disclosure of formularies to facilitate comparison shopping among individual health benefit plans.
(b) The requirements adopted under Subsection (a) must apply to each prescription drug:
(1) included in a formulary and dispensed in a network pharmacy; or
(2) covered under an individual health benefit plan and typically administered by a physician or health care provider.
(c) The formulary disclosures must:
(1) be electronically searchable by drug name;
(2) include for each drug the information required by Subsection (d) in the order listed in that subsection; and
(3) indicate each formulary that applies to each individual health benefit plan issued by the issuer.
(d) The formulary disclosures must include for each drug:
(1) the cost-sharing amount for each drug, including as applicable:
(A) the dollar amount of a copayment; or
(B) for a drug subject to coinsurance:
(i) an enrollee's cost-sharing amount stated in dollars; or
(ii) a cost-sharing range, denoted as follows:
(a) under $100 - $;
(b) $100-$250 - $$;
(c) $251-$500 - $$$;
(d) $501-$1,000 - $$$$; or
(e) over $1,000 - $$$$$;
(2) a disclosure of prior authorization, step therapy, or other protocol requirements for each drug;
(3) if the individual health benefit plan uses a tier-based formulary, the specific tier for each drug listed in the formulary;
(4) a description of how prescription drugs will specifically be included in or excluded from the deductible, including a description of out-of-pocket costs for a prescription drug that may not apply to the deductible;
(5) identification of preferred formulary drugs; and
(6) an explanation of coverage of each formulary drug.
(e) The commissioner by rule may allow an alternative method of making disclosures required under Subsection (d)(1) relating to cost-sharing through a web-based tool that must:
(1) be publicly accessible to enrollees, prospective enrollees, and others without necessity of providing a password, a user name, or personally identifiable information;
(2) allow consumers to electronically search formulary information by the name under which the individual health benefit plan is marketed; and
(3) be accessible through a direct link that is displayed on each page of the formulary disclosure that lists each drug as required under Subsection (c).
Added by Acts 2015, 84th Leg., R.S., Ch. 1038 (H.B. 1624), Sec. 1, eff. September 1, 2015.
Transferred, redesignated and amended from Insurance Code, Section 1369.0543 by Acts 2017, 85th Leg., R.S., Ch. 135 (H.B. 1227), Sec. 2, eff. September 1, 2017.

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