Tex. INSURANCE CODE NOT CODIFIED tit. 1, ch. 21, subch. E, art. 21.52B

Current with legislation from the 2023 Regular and Special Sessions signed by the Governor as of November 21, 2023.

Article 21.52B - PHARMACEUTICAL SERVICES

Sec. 1. DEFINITIONS. In this article:

(1) "Health insurance policy" means an individual, group, blanket, or franchise insurance policy, insurance policy or agreement, or group hospital service contract that provides benefits for pharmaceutical services that are necessary as a result of or to prevent an accident or sickness, but does not include evidence of coverage provided by a health maintenance organization under the Texas Health Maintenance Organization Act (Chapter 20A, Vernon's Texas Insurance Code).

(2) "Pharmaceutical services" means services, including dispensing prescription drugs, that are ordinarily and customarily rendered by a pharmacy or pharmacist licensed to practice pharmacy under the Texas Pharmacy Act (Article 4542a-1, Vernon's Texas Civil Statutes).

(3) "Pharmacist" means a person licensed to practice pharmacy under the Texas Pharmacy Act (Article 4542a-1, Vernon's Texas Civil Statutes).

(4) "Pharmacy" means a facility licensed as a pharmacy under the Texas Pharmacy Act (Article 4542a-1, Vernon's Texas Civil Statutes).

(5) "Drugs" and "prescription drugs" have the meanings assigned by Section 5, Texas Pharmacy Act (Article 4542a-1, Vernon's Texas Civil Statutes).

(6) "Managed care plan" means a health maintenance organization, a preferred provider organization, or another organization that, under a contract or other agreement entered into with a participant in the plan:

(A) provides health care benefits, or arranges for health care benefits to be provided, to a participant in the plan; and

(B) requires or encourages those participants to use health care providers designated by the plan.

Sec. 2. PROHIBITED CONTRACTUAL PROVISIONS.

(a) A health insurance policy or managed care plan that is delivered, issued for delivery, or renewed or for which a contract or other agreement is executed may not:

(1) prohibit or limit a person who is a beneficiary of the policy from selecting a pharmacy or pharmacist of the person's choice to be a provider under the policy to furnish pharmaceutical services offered or provided by that policy or interfere with that person's selection of a pharmacy or pharmacist;

(2) deny a pharmacy or pharmacist the right to participate as a contract provider under the policy or plan if the pharmacy or pharmacist agrees to provide pharmaceutical services that meet all terms and requirements and to include the same administrative, financial, and professional conditions that apply to pharmacies and pharmacists who have been designated as providers under the policy or plan; or

(3) require a beneficiary of a policy or a participant in a plan to obtain or request a specific quantity or dosage supply of pharmaceutical products.

(b) Notwithstanding Subsection (a)(3) of this section, a health insurance policy or managed care plan may allow the physician of a beneficiary or participant to prescribe drugs in a quantity or dosage supply the physician determines appropriate and that is in compliance with state and federal statutes.

(c) This section does not prohibit:

(1) a provision of a policy or plan from limiting the quantity or dosage supply of pharmaceutical products for which coverage is provided or providing financial incentives to encourage the beneficiary or participant and the prescribing physician to use a program that provides pharmaceutical products in quantities that result in cost savings to the insurance program or managed care plan and the beneficiary or participant if the provision applies equally to all designated providers of pharmaceutical services under the policy or plan;

(2) a pharmacy card program that provides a means of obtaining pharmaceutical services offered by the policy or plan through all designated providers of pharmaceutical services; or

(3) a plan from establishing reasonable application and recertification fees for a pharmacy which provides pharmaceutical services as a contract provider under the plan, provided that such fees are uniformly charged to each pharmacy under contract to the plan.

Sec. 3. PROVISION VOID. A provision of a health insurance policy or managed care plan that is delivered, issued for delivery, entered into, or renewed in this state that conflicts with Section 2 of this article is void to the extent of the conflict.

Sec. 4. CONSTRUCTION OF ARTICLE. This article does not require a health insurance policy or managed care plan to provide pharmaceutical services.

Sec. 5. APPLICATION OF PROHIBITION. The provisions of Section 2 of this article do not apply to a self-insured employee benefit plan that is subject to the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001, et seq.).

Sec. 6. Repealed by Acts 1993, 73rd Leg., ch. 685, Sec. 19.06, eff. Aug. 30, 1993.

Tex. INSURANCE CODE NOT CODIFIED tit. 1, ch. 21, subch. E, art. 21.52B

Added by Acts 1991, 72nd Leg., ch. 182, Sec. 1, eff. 9/1/1991. Sec. 2(b) amended by Acts 1993, 73rd Leg., ch. 685, Sec. 19.07, eff. 9/1/1993; Sec. 5 amended by Acts 1993, 73rd Leg., ch. 685, Sec. 19.08, eff. 9/1/1993; Sec. 6 repealed by Acts 1993, 73rd Leg., ch. 685, Sec. 19.06, eff. 8/30/1993; Sec. 1(6) added by Acts 1995, 74th Leg., ch. 852, Sec. 1, eff. 9/1/1995; Sec. 2 amended by Acts 1995, 74th Leg., ch. 852, Sec. 2, eff. 9/1/1995; Sec. 3 amended by Acts 1995, 74th Leg., ch. 852, Sec. 3, eff. 9/1/1995; Sec. 4 amended by Acts 1995, 74th Leg., ch. 852, Sec. 4, eff. 9/1/1995.