Tex. Ins. Code Section 1369.259
Calculation of Recoupment; Use of Extrapolation Prohibited

(a)

A health benefit plan issuer or pharmacy benefit manager may not calculate the amount of a recoupment based on:

(1)

an absence of documentation the pharmacist or pharmacy is not required by applicable federal laws and regulations and state laws and rules to maintain; or

(2)

an error that does not result in actual financial harm to the patient or enrollee, the health benefit plan issuer, or the pharmacy benefit manager.

(b)

A health benefit plan issuer or pharmacy benefit manager may not require extrapolation audits as a condition of participation in a contract, network, or program for a pharmacist or pharmacy.

(c)

A health benefit plan issuer or pharmacy benefit manager may not use extrapolation to complete an on-site audit or a desk audit of a pharmacist or pharmacy. Notwithstanding Subsection (a)(2), the amount of a recoupment must be based on the actual overpayment or underpayment and may not be based on an extrapolation.

(d)

A health benefit plan issuer or pharmacy benefit manager may not include a dispensing fee amount in the calculation of an overpayment unless:

(1)

the fee was a duplicate charge;

(2)

the prescription for which the fee was charged:

(A)

was not dispensed; or

(B)

was dispensed:
(i)
without the prescriber’s authorization;
(ii)
to the wrong patient; or
(iii)
with the wrong instructions; or

(3)

the wrong drug was dispensed.
Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.

Source: Section 1369.259 — Calculation of Recoupment; Use of Extrapolation Prohibited, https://statutes.­capitol.­texas.­gov/Docs/IN/htm/IN.­1369.­htm#1369.­259 (accessed Jun. 5, 2024).

1369.001
Definitions 1369.002
Applicability of Subchapter 1369.003
Exception 1369.004
Coverage Required 1369.005
Rules 1369.0041
Certain Payments and Refills 1369.051
Definitions 1369.052
Applicability of Subchapter 1369.053
Exception 1369.054
Notice and Disclosure of Certain Information Required 1369.055
Continuation of Coverage Required 1369.056
Adverse Determination 1369.057
Rules 1369.076
Definitions 1369.077
Applicability of Subchapter 1369.078
Formulary Information on Internet Website 1369.079
Formulary Disclosure Requirements 1369.080
Formulary Information Provided by Toll-free Telephone Number 1369.091
Definitions 1369.092
Applicability of Subchapter 1369.093
Exceptions to Applicability of Subchapter 1369.094
Disclosure of Prescription Drug Information 1369.101
Definitions 1369.102
Applicability of Subchapter 1369.103
Exception 1369.104
Exclusion or Limitation Prohibited 1369.105
Certain Cost-sharing Provisions Prohibited 1369.106
Certain Waiting Periods Prohibited 1369.107
Prohibited Conduct 1369.108
Exemption for Entities Associated with Religious Organization 1369.109
Enforcement 1369.151
Applicability of Subchapter 1369.152
Exception 1369.153
Information Required on Identification Card 1369.154
Rules 1369.201
Definitions 1369.202
Applicability of Subchapter 1369.203
Exception 1369.204
Required Coverage for Orally Administered Anticancer Medications 1369.211
Definitions 1369.212
Applicability of Subchapter 1369.213
Prohibited Conduct 1369.251
Definitions 1369.252
Exceptions to Applicability of Subchapter 1369.253
Conflict with Other Laws 1369.254
Audit of Pharmacist or Pharmacy 1369.255
Completion of Audit 1369.256
Audit Requiring Professional Judgment 1369.257
Access to Pharmacy Area 1369.258
Validation Using Certain Records Authorized 1369.259
Calculation of Recoupment 1369.260
Clerical or Recordkeeping Error 1369.261
Access to Previous Audit Reports 1369.262
Compensation of Auditor 1369.263
Conclusion of Audit 1369.264
Final Audit Report 1369.265
Certain Audits Exempt from Deadlines 1369.266
Recoupment and Interest Charged After Audit 1369.267
Waiver Prohibited 1369.268
Remedies Not Exclusive 1369.269
Enforcement 1369.270
Legislative Declaration 1369.301
Definition 1369.302
Applicability of Subchapter 1369.303
Exception 1369.304
Standard Form 1369.305
Advisory Committee on Uniform Prior Authorization Forms 1369.306
Failure to Use or Acknowledge Standard Form 1369.351
Definitions 1369.352
Certain Benefits Excluded 1369.353
Criteria for Drugs on Maximum Allowable Cost Lists 1369.354
Formulation of Maximum Allowable Costs 1369.355
Updates 1369.356
Access to Maximum Allowable Cost Lists 1369.357
Appeal from Maximum Allowable Cost Price Determination 1369.358
Confidentiality of Maximum Allowable Cost List 1369.359
Waiver Prohibited 1369.360
Remedies Not Exclusive 1369.361
Enforcement 1369.362
Legislative Declaration 1369.401
Definition 1369.402
Certain Fees Prohibited 1369.451
Definitions 1369.452
Applicability of Subchapter 1369.453
Applicability to Certain Medications 1369.454
Proration of Cost-sharing Amount Required 1369.455
Proration of Dispensing Fee Prohibited 1369.456
Implementation of Certain Medication Synchronization Plans 1369.501
Definitions 1369.502
Pharmacy Benefit Manager Information 1369.503
Health Benefit Plan Issuer Information 1369.504
Rules 1369.0541
Modification of Drug Coverage Under Plan 1369.0542
Effect of Reductions in Out-of-pocket Expenses on Cost Sharing 1369.0545
Step Therapy Protocols 1369.0546
Step Therapy Protocol Exception Requests 1369.0547
Step Therapy Protocols for Prescription Drugs to Treat Serious Mental Illnesses 1369.551
Definitions 1369.552
Exceptions to Applicability of Subchapter 1369.553
Transfer or Acceptance of Certain Records Prohibited 1369.554
Prohibition on Certain Communications 1369.555
Prohibition on Certain Referrals and Solicitations 1369.601
Definitions 1369.602
Applicability of Subchapter 1369.603
Reduction of Certain Claim Payment Amounts Prohibited 1369.604
Reimbursement of Affiliated and Nonaffiliated Pharmacists and Pharmacies 1369.605
Network Contract Fee Schedule 1369.606
Disclosure of Pharmacy Services Administrative Organization Contract 1369.607
Delivery of Drugs 1369.608
Professional Standards and Scope of Practice Requirements 1369.609
Retaliation Prohibited 1369.610
Waiver Prohibited 1369.651
Definition 1369.652
Applicability of Subchapter 1369.653
Exceptions 1369.654
Prohibition on Multiple Prior Authorizations 1369.761
Definitions 1369.762
Applicability of Subchapter 1369.763
Exceptions to Applicability of Subchapter 1369.764
Certain Limitations on Coverage of Clinician-administered Drugs Prohibited 1369.1031
Certain Coverage Required 1369.2581
Audit Discrepancies 1369.5035
Content of Reports
Green check means up to date. Up to date

Accessed:
Jun. 5, 2024

§ 1369.259’s source at texas​.gov