28 Tex. Admin. Code § 11.1605 - Pharmaceutical Services

(a) Prescription drug coverage that includes copayments must do so for both generic drugs and name-brand drugs. If the negotiated or usual and customary cost of the drug is less than the copayment, the enrollee may only be required to pay the lower cost. The copayments may be the same, or if different, must be applied as follows:

(1) if the prescription is for a generic drug, the enrollee may be required to pay no more than the generic copayment;

(2) if the prescription is for a name-brand drug, the enrollee may be required to pay no more than the name-brand copayment if:

(A) the prescription is written "dispense as written"; or

(B) there is no generic equivalent for the prescribed drug;

(3) if the prescription is written "product selection permitted" and the enrollee elects to receive a name-brand drug when a generic equivalent is available, then the enrollee may be required to pay no more than the generic copayment plus the difference between the cost of the generic drug and the cost of the name-brand drug; and

(4) if the enrollee's prescription benefit requires the use of generic-equivalent drugs (required generic) and the enrollee receives a name-brand drug when a generic equivalent is available, then the enrollee may be required to pay no more than the generic copayment plus the difference between the cost of the generic drug and the cost of the name-brand drug, even when the prescription is written "dispense as written."

(b) Pharmacy service must be available and accessible within the service area for the enrolled population through pharmacies licensed by the Texas State Board of Pharmacy. The HMO must offer the pharmacy services directly or through contracts.

Notes

28 Tex. Admin. Code § 11.1605

The provisions of this §11.1605 adopted to be effective November 2, 1998, 23 TexReg 11347; amended to be effective February 24, 2005, 30 TexReg 854; amended to be effective November 15, 2006, 31 TexReg 9298; Adopted by Texas Register, Volume 42, Number 16, April 21, 2017, TexReg 2253, eff. 8/1/2017