Section 1369.004 - Coverage Required(a) A health benefit plan that covers drugs must cover any drug prescribed to treat an enrollee for a chronic, disabling, or life-threatening illness covered under the plan if the drug:(1) has been approved by the United States Food and Drug Administration for at least one indication; and(2) is recognized by the following for treatment of the indication for which the drug is prescribed: (A) a prescription drug reference compendium approved by the commissioner for purposes of this section; or(B) substantially accepted peer-reviewed medical literature.(b) Coverage of a drug required under Subsection (a) must include coverage of medically necessary services associated with the administration of the drug.(c) A health benefit plan issuer may not, based on a "medical necessity" requirement, deny coverage of a drug required under Subsection (a) unless the reason for the denial is unrelated to the legal status of the drug use.(d) This section does not require a health benefit plan to cover: (1) experimental drugs that are not otherwise approved for an indication by the United States Food and Drug Administration;(2) any disease or condition that is excluded from coverage under the plan; or(3) a drug that the United States Food and Drug Administration has determined to be contraindicated for treatment of the current indication.Tex. Ins. Code § 1369.004
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. 4/1/2005.