28 Tex. Admin. Code § 21.3022 - Continuation of Benefits

(a) An issuer of a health benefit plan that offers prescription drug benefits must make a prescription drug that was approved or covered for a medical condition or mental illness available to each enrollee at the contracted benefit level until the health benefit plan renewal date. Modifications to drug coverage are not permitted until the plan's renewal date.

(b) A health benefit plan issuer may make modifications to drug coverage provided under a health benefit plan if:

(1) the modification occurs at the time of coverage renewal;

(2) the modification is effective uniformly among all group health benefit plan sponsors covered by identical or substantially identical health benefit plans, or all individuals covered by identical or substantially identical individual health benefit plans, as applicable; and

(3) not later than the 60th day before the date the modification is effective, the issuer provides written notice of the modification to the commissioner, each affected group health benefit plan sponsor, each affected enrollee in an affected group health benefit plan, and each affected individual health benefit plan holder for modifications that:

(A) remove a drug from a formulary;

(B) add a requirement that an enrollee receive prior authorization for a drug;

(C) impose or alter a quantity limit for a drug;

(D) impose a step-therapy restriction for a drug; or

(E) move a drug to a higher cost-sharing tier unless a generic drug alternative is available.

(c) For purposes of this section, modifications that are more favorable to the consumer may be made without notice at any time, including modifications that:

(1) add drugs to formularies;

(2) reduce cost sharing; or

(3) delete a utilization review requirement.

Notes

28 Tex. Admin. Code § 21.3022

The provisions of this §21.3022 adopted to be effective December 20, 2000, 25 TexReg 12437; Amended by Texas Register, Volume 41, Number 33, August 12, 2016, TexReg 6043, eff. 8/18/2016