Tex.
Ins. Code Section 1369.004
Coverage Required
(a)
A health benefit plan that covers drugs must cover any drug prescribed to treat an enrollee for a chronic, disabling, or life-threatening illness covered under the plan if the drug:(1)
has been approved by the United States Food and Drug Administration for at least one indication; and(2)
is recognized by the following for treatment of the indication for which the drug is prescribed:(A)
a prescription drug reference compendium approved by the commissioner for purposes of this section; or(B)
substantially accepted peer-reviewed medical literature.(b)
Coverage of a drug required under Subsection (a) must include coverage of medically necessary services associated with the administration of the drug.(c)
A health benefit plan issuer may not, based on a “medical necessity” requirement, deny coverage of a drug required under Subsection (a) unless the reason for the denial is unrelated to the legal status of the drug use.(d)
This section does not require a health benefit plan to cover:(1)
experimental drugs that are not otherwise approved for an indication by the United States Food and Drug Administration;(2)
any disease or condition that is excluded from coverage under the plan; or(3)
a drug that the United States Food and Drug Administration has determined to be contraindicated for treatment of the current indication.
Source:
Section 1369.004 — Coverage Required, https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1369.htm#1369.004 (accessed Jun. 5, 2024).
