Tex.
Ins. Code Section 1369.764
Certain Limitations on Coverage of Clinician-administered Drugs Prohibited
(a)
Subject to Subsection (b), a health benefit plan issuer may not, for an enrollee with a chronic, complex, rare, or life-threatening medical condition:(1)
require clinician-administered drugs to be dispensed only by certain pharmacies or only by pharmacies participating in the health benefit plan issuer’s network;(2)
if a clinician-administered drug is otherwise covered, limit or exclude coverage for such drugs based on the enrollee’s choice of pharmacy or because the drug was not dispensed by a pharmacy that participates in the health benefit plan issuer’s network;(3)
require a physician or health care provider participating in the health benefit plan issuer’s network to bill for or be reimbursed for the delivery and administration of clinician-administered drugs under the pharmacy benefit instead of the medical benefit without:(A)
informed written consent of the patient; and(B)
a written attestation by the patient’s physician or health care provider that a delay in the drug’s administration will not place the patient at an increased health risk; or(4)
require that an enrollee pay an additional fee, higher copay, higher coinsurance, second copay, second coinsurance, or any other price increase for clinician-administered drugs based on the enrollee’s choice of pharmacy or because the drug was not dispensed by a pharmacy that participates in the health benefit plan issuer’s network.(b)
Subsection (a) applies only if the patient’s physician or health care provider determines that:(1)
a delay of care would make disease progression probable; or(2)
the use of a pharmacy within the health benefit plan issuer’s network would:(A)
make death or patient harm probable;(B)
potentially cause a barrier to the patient’s adherence to or compliance with the patient’s plan of care; or(C)
because of the timeliness of the delivery or dosage requirements, necessitate delivery by a different pharmacy.(c)
Nothing in this section may be construed to:(1)
authorize a person to administer a drug when otherwise prohibited under the laws of this state or federal law; or(2)
modify drug administration requirements under the laws of this state, including any requirements related to delegation and supervision of drug administration.
Source:
Section 1369.764 — Certain Limitations on Coverage of Clinician-administered Drugs Prohibited, https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1369.htm#1369.764 (accessed Jun. 5, 2024).
