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Current as of January 01, 2024 | Updated by Findlaw Staff
(a) This section applies only to a reduction in out-of-pocket expenses made by or on behalf of an enrollee for a prescription drug covered by the enrollee's health benefit plan for which:
(1) a generic equivalent does not exist;
(2) a generic equivalent does exist but the enrollee has obtained access to the prescription drug under the enrollee's health benefit plan using:
(A) a prior authorization process;
(B) a step therapy protocol; or
(C) the health benefit plan issuer's exceptions and appeals process;
(3) an interchangeable biological product does not exist; or
(4) an interchangeable biological product does exist but the enrollee has obtained access to the prescription drug under the enrollee's health benefit plan using:
(A) a prior authorization process;
(B) a step therapy protocol; or
(C) the health benefit plan issuer's exceptions and appeals process.
(b) An issuer of a health benefit plan that covers prescription drugs or a pharmacy benefit manager shall apply any third-party payment, financial assistance, discount, product voucher, or other reduction in out-of-pocket expenses made by or on behalf of an enrollee for a prescription drug to the enrollee's deductible, copayment, cost-sharing responsibility, or out-of-pocket maximum applicable to health benefits under the enrollee's plan.
Cite this article: FindLaw.com - Texas Insurance Code - INS § 1369.0542. Effect of Reductions in Out-of-Pocket Expenses on Cost Sharing - last updated January 01, 2024 | https://codes.findlaw.com/tx/insurance-code/ins-sect-1369-0542/
FindLaw Codes may not reflect the most recent version of the law in your jurisdiction. Please verify the status of the code you are researching with the state legislature before relying on it for your legal needs.
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