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.
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 May 18, 2024).
