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Texas Insurance Code - INS § 1369.004. Coverage Required

Current as of January 01, 2024 | Updated by Findlaw Staff

(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.

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Cite this article: FindLaw.com - Texas Insurance Code - INS § 1369.004. Coverage Required - last updated January 01, 2024 | https://codes.findlaw.com/tx/insurance-code/ins-sect-1369-004/

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