Texas Insurance Code - INS § 1369.259. Limitations on Payment Adjustments and Recoupment;  Use of Extrapolation Prohibited

(a) A health benefit plan issuer or pharmacy benefit manager may not calculate the amount of a recoupment based on:

(a-1) Subject to Subsections (e) and (f), a health benefit plan issuer or pharmacy benefit manager may not, as the result of an audit, deny or reduce a claim payment made to a pharmacist or pharmacy after adjudication of the claim.

(b) A health benefit plan issuer or pharmacy benefit manager may not require extrapolation audits as a condition of participation in a contract, network, or program for a pharmacist or pharmacy.

(c) A health benefit plan issuer or pharmacy benefit manager may not use extrapolation to complete an on-site audit or a desk audit of a pharmacist or pharmacy.  Notwithstanding Subsection (a)(2), the amount of a recoupment must be based on the actual overpayment or underpayment and may not be based on an extrapolation.

(d) Repealed by Acts 2025, 89th Leg., ch. 183 (S.B. 1236), § 6, eff. Sept. 1, 2025.

(e) A health benefit plan issuer or pharmacy benefit manager may recoup from a pharmacist or pharmacy the cost of a prescription drug and the dispensing fee for the drug if:

(f) A health benefit plan issuer or pharmacy benefit manager may recoup only the dispensing fee from a pharmacist or pharmacy if the pharmacist or pharmacy made a clerical error that led to an overpayment.