Tex. Ins. Code Section 1451.1261
Reimbursement for Certain Services and Procedures Performed by Pharmacists


(a)

Notwithstanding any other law, in addition to applying to a policy, agreement, or contract described by Section 1451.102 (Applicability of Subchapter), this section applies to any other individual or group health benefit plan that provides benefits described by Section 1451.102 (Applicability of Subchapter), including:

(1)

a health benefit plan issued by:

(A)

a group hospital service corporation operating under Chapter 842 (Group Hospital Service Corporations);

(B)

a health maintenance organization operating under Chapter 843 (Health Maintenance Organizations); or

(C)

a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846 (Multiple Employer Welfare Arrangements);

(2)

a small employer health benefit plan subject to Chapter 1501 (Health Insurance Portability and Availability Act);

(3)

a standard health benefit plan issued under Chapter 1507 (Consumer Choice of Benefits Plans);

(4)

health benefits provided by or through a church benefits board under Subchapter I (Definition), Chapter 22 (Nonprofit Corporations), Business Organizations Code;

(5)

a regional or local health care program operated under Section 75.104 (Health Care Services), Health and Safety Code; and

(6)

a self-funded health benefit plan sponsored by a professional employer organization under Chapter 91 (Professional Employer Organizations), Labor Code.

(b)

This section does not apply to:

(1)

a basic coverage plan under Chapter 1551 (Texas Employees Group Benefits Act);

(2)

a basic plan under Chapter 1575 (Texas Public School Employees Group Benefits Program);

(3)

a primary care coverage plan under Chapter 1579 (Texas School Employees Uniform Group Health Coverage);

(4)

a plan providing basic coverage under Chapter 1601 (Uniform Insurance Benefits Act for Employees of the University of Texas System and the Texas A&m University System);

(5)

the state Medicaid program, including the Medicaid managed care program operated under Chapter 533, Government Code; or

(6)

the child health plan program under Chapter 62 (Child Health Plan for Certain Low-income Children), Health and Safety Code.

(b)

This section does not apply to:

(1)

a basic coverage plan under Chapter 1551 (Texas Employees Group Benefits Act);

(2)

a basic plan under Chapter 1575 (Texas Public School Employees Group Benefits Program);

(3)

a primary care coverage plan under Chapter 1579 (Texas School Employees Uniform Group Health Coverage);

(4)

a plan providing basic coverage under Chapter 1601 (Uniform Insurance Benefits Act for Employees of the University of Texas System and the Texas A&m University System);

(5)

the state Medicaid program, including the Medicaid managed care program operated under Chapters 540 (Medicaid Managed Care Program) and 540A (Medicaid Managed Transportation Services), Government Code; or

(6)

the child health plan program under Chapter 62 (Child Health Plan for Certain Low-income Children), Health and Safety Code.

(c)

Notwithstanding Section 1451.102 (Applicability of Subchapter), this section applies to coverage under a group health benefit plan provided to a resident of this state regardless of whether the group policy, agreement, or contract is delivered, issued for delivery, or renewed in this state.

(d)

An insurer or other health benefit plan issuer or a third-party administrator or pharmacy benefit manager of a health benefit plan may not deny reimbursement to a pharmacist for the provision of a service or procedure within the scope of the pharmacist’s license to practice pharmacy under Subtitle J, Title 3, Occupations Code, that:

(1)

would be covered by the insurance policy or other coverage agreement if the service or procedure were provided by:

(A)

a physician;

(B)

an advanced practice nurse; or

(C)

a physician assistant; and

(2)

is performed by the pharmacist in strict compliance with laws and rules related to:

(A)

the provision of the service or procedure; and

(B)

the pharmacist’s license.

(e)

This section may not be construed to require an insurer or other health benefit plan issuer or a third-party administrator or pharmacy benefit manager to reimburse a pharmacist or pharmacy as an in-network or preferred provider.
Added by Acts 2019, 86th Leg., R.S., Ch. 324 (H.B. 3441), Sec. 1, eff. September 1, 2019.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.131, eff. April 1, 2025.

Source: Section 1451.1261 — Reimbursement for Certain Services and Procedures Performed by Pharmacists, https://statutes.­capitol.­texas.­gov/Docs/IN/htm/IN.­1451.­htm#1451.­1261 (accessed Jun. 5, 2024).

1451.001
Definitions
1451.051
Applicability of Subchapter
1451.052
Applicability of General Provisions of Other Law
1451.053
Practitioner Designation
1451.054
Terms Used to Designate Health Care Practitioners
1451.101
Definitions
1451.102
Applicability of Subchapter
1451.103
Conflicting Provisions Void
1451.104
Nondiscriminatory Payment or Reimbursement
1451.105
Selection of Acupuncturist
1451.106
Selection of Advanced Practice Nurse
1451.107
Selection of Audiologist
1451.108
Selection of Chemical Dependency Counselor
1451.109
Selection of Chiropractor
1451.110
Selection of Dentist
1451.111
Selection of Dietitian
1451.112
Selection of Hearing Instrument Fitter and Dispenser
1451.113
Selection of Licensed Clinical Social Worker
1451.114
Selection of Licensed Professional Counselor
1451.115
Selection of Surgical Assistant
1451.116
Selection of Marriage and Family Therapist
1451.117
Selection of Nurse First Assistant
1451.118
Selection of Occupational Therapist
1451.119
Selection of Optometrist
1451.120
Selection of Physical Therapist
1451.121
Selection of Physician Assistant
1451.122
Selection of Podiatrist
1451.123
Selection of Psychological Associate
1451.124
Selection of Psychologist
1451.125
Selection of Speech-language Pathologist
1451.126
Reimbursement for Physical Modalities and Procedures by Health Insurer, Administrator, Health Maintenance Organization, or Preferred Provider Benefit Plan Issuer
1451.127
Duty of Person Arranging Provider Contracts for Health Insurer or Health Maintenance Organization
1451.128
Selection of Pharmacist
1451.151
Definition
1451.152
Applicability and Construction of Subchapter
1451.153
Use of Optometrist or Therapeutic Optometrist
1451.154
Participation of Therapeutic Optometrist
1451.155
Contracts with Optometrists or Therapeutic Optometrists
1451.156
Certain Conduct Prohibited
1451.157
Extrapolation Prohibited
1451.158
Enforcement of Subchapter
1451.201
Definitions
1451.202
Applicability and Construction of Subchapter
1451.203
Conflicting Provisions
1451.204
Certain Conduct Permitted
1451.205
Disclosure of Benefit Terms
1451.206
Payment or Reimbursement of Dentist
1451.207
Prohibited Conduct
1451.208
Prior Authorization of Dental Care Services
1451.209
Requirements for Third Party Access to Provider Networks
1451.251
Definition
1451.252
Applicability of Subchapter
1451.253
Exception
1451.254
Rules
1451.255
Right of Female Enrollee to Select Obstetrician or Gynecologist
1451.256
Direct Access to Services of Obstetrician or Gynecologist
1451.257
Availability of Providers
1451.258
Notice of Available Providers
1451.259
Limits on Physician Sanctions
1451.260
Administrative Penalty
1451.301
Applicability of General Provisions of Other Law
1451.302
Dietitian Services
1451.351
Loss of Income Benefits for Disability Treatable by Podiatrist
1451.401
Contract with Osteopathic Hospital
1451.402
Services at Osteopathic Hospital
1451.403
Request for Action of Commissioner
1451.404
Enforcement
1451.451
Reimbursement Under Medicaid-based Fee Schedule
1451.501
Definitions
1451.502
Applicability of Subchapter
1451.503
Exception
1451.504
Physician and Health Care Provider Directories
1451.505
Physician and Health Care Provider Directory on Internet Website
1451.1261
Reimbursement for Certain Services and Procedures Performed by Pharmacists
1451.2065
Contracts with Dentists

Accessed:
Jun. 5, 2024

§ 1451.1261’s source at texas​.gov