Section 1369.764 - Certain Limitations On Coverage Of Clinician-Administered Drugs Prohibited(a) Subject to Subsection (b), a health benefit plan issuer may not, for an enrollee with a chronic, complex, rare, or life-threatening medical condition: (1) require clinician-administered drugs to be dispensed only by certain pharmacies or only by pharmacies participating in the health benefit plan issuer's network; (2) if a clinician-administered drug is otherwise covered, limit or exclude coverage for such drugs based on the enrollee's choice of pharmacy or because the drug was not dispensed by a pharmacy that participates in the health benefit plan issuer's network; (3) require a physician or health care provider participating in the health benefit plan issuer's network to bill for or be reimbursed for the delivery and administration of clinician-administered drugs under the pharmacy benefit instead of the medical benefit without: (A) informed written consent of the patient; and (B) a written attestation by the patient's physician or health care provider that a delay in the drug's administration will not place the patient at an increased health risk; or (4) require that an enrollee pay an additional fee, higher copay, higher coinsurance, second copay, second coinsurance, or any other price increase for clinician-administered drugs based on the enrollee's choice of pharmacy or because the drug was not dispensed by a pharmacy that participates in the health benefit plan issuer's network. (b) Subsection (a) applies only if the patient's physician or health care provider determines that: (1) a delay of care would make disease progression probable; or (2) the use of a pharmacy within the health benefit plan issuer's network would: (A) make death or patient harm probable; (B) potentially cause a barrier to the patient's adherence to or compliance with the patient's plan of care; or (C) because of the timeliness of the delivery or dosage requirements, necessitate delivery by a different pharmacy. (c) Nothing in this section may be construed to: (1) authorize a person to administer a drug when otherwise prohibited under the laws of this state or federal law; or (2) modify drug administration requirements under the laws of this state, including any requirements related to delegation and supervision of drug administration. Tex. Ins. Code § 1369.764
Added by Acts 2023, Texas Acts of the 88th Leg.- Regular Session, ch. 417,Sec. 1, 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.