Section 1369.0542 - Effect Of Reductions In Out-Of-Pocket Expenses On Cost Sharing(a) This section applies only to a reduction in out-of-pocket expenses made by or on behalf of an enrollee for a prescription drug covered by the enrollee's health benefit plan for which: (1) a generic equivalent does not exist; (2) a generic equivalent does exist but the enrollee has obtained access to the prescription drug under the enrollee's health benefit plan using: (A) a prior authorization process; (B) a step therapy protocol; or (C) the health benefit plan issuer's exceptions and appeals process; (3) an interchangeable biological product does not exist; or (4) an interchangeable biological product does exist but the enrollee has obtained access to the prescription drug under the enrollee's health benefit plan using: (A) a prior authorization process; (B) a step therapy protocol; or (C) the health benefit plan issuer's exceptions and appeals process. (b) An issuer of a health benefit plan that covers prescription drugs or a pharmacy benefit manager shall apply any third-party payment, financial assistance, discount, product voucher, or other reduction in out-of-pocket expenses made by or on behalf of an enrollee for a prescription drug to the enrollee's deductible, copayment, cost-sharing responsibility, or out-of-pocket maximum applicable to health benefits under the enrollee's plan. Tex. Ins. Code § 1369.0542
Added by Acts 2023, Texas Acts of the 88th Leg.- Regular Session, ch. 489,Sec. 2, eff. 9/1/2023, app. only to a health benefit plan that is delivered, issued for delivery, or renewed on or after January 1, 2024.