Section 21.3032 - Formulary Disclosure Requirements for Individual Health Benefit Plans(a) The formulary information required under this section must include each individual prescription drug covered under the plan that is dispensed in a network pharmacy or administered by a physician or health care provider and clearly differentiate between drugs covered under the plan's pharmacy benefits and medical benefits. Information pertaining to drugs covered under the plan's medical benefits may be provided as an addendum or link to the formulary and must include each parameter that is applicable.(b) The formulary information must include the following coverage information for each drug: (1) an explanation of coverage under the health benefit plan;(2) an indication of whether the drug is preferred, if applicable, under the plan;(3) a disclosure of any prior authorization, step therapy, or other protocol requirement; and(4) the specific tier the drug falls under, if the plan uses a multitier formulary.(c) The formulary information must include the following plan-specific cost-sharing information for each drug: (1) whether the drug is subject to a pharmacy or medical deductible and where the deductible may be found;(2) the cost-sharing amount for each drug under the pharmacy or medical benefit, in a retail, mail order, or physician- or practitioner-administered setting, if applicable, excluding any deductible requirement, including, as applicable: (A) the dollar amount of a copayment; and(B) for a drug subject to coinsurance: (i) an enrollee's cost-sharing amount stated in dollars; or(ii) a cost-sharing range denoted as follows:(IV) $501 - $1,000 - $$$$; or(d) Cost-sharing amounts must reflect the cost to the consumer, rounded to the next highest dollar amount, for a month-long supply unless otherwise noted. Cost-sharing information reflecting the cost for a different duration supply should indicate the applicable duration. The cost-sharing amount for a given drug must be calculated based on the plan's median allowed amount or the actual cost for the drug, using the most up-to-date data available and the cost-sharing parameters under the enrollee's health benefit plan for the tier under which the drug is assigned. The information must include whether the cost-sharing amount is based on the median or the actual cost.(e) Any formulary information presented using abbreviations must provide a legend on each page explaining the meaning of each abbreviation used, including the dollar amounts that correspond to the cost-sharing range.28 Tex. Admin. Code § 21.3032
Adopted by Texas Register, Volume 41, Number 33, August 12, 2016, TexReg 6043, eff. 8/18/2016; Amended by Texas Register, Volume 43, Number 20, May 18, 2018, TexReg 3243, eff. 5/21/2018