Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS
Subchapter Q - OTHER REQUIREMENTS
Section 11.1605 - Pharmaceutical Services

Universal Citation: 28 TX Admin Code § 11.1605

Current through Reg. 50, No. 13; March 28, 2025

(a) Prescription drug coverage that includes copayments must do so for both generic drugs and name-brand drugs. If the negotiated or usual and customary cost of the drug is less than the copayment, the enrollee may only be required to pay the lower cost. The copayments may be the same, or if different, must be applied as follows:

(1) if the prescription is for a generic drug, the enrollee may be required to pay no more than the generic copayment;

(2) if the prescription is for a name-brand drug, the enrollee may be required to pay no more than the name-brand copayment if:
(A) the prescription is written "dispense as written"; or

(B) there is no generic equivalent for the prescribed drug;

(3) if the prescription is written "product selection permitted" and the enrollee elects to receive a name-brand drug when a generic equivalent is available, then the enrollee may be required to pay no more than the generic copayment plus the difference between the cost of the generic drug and the cost of the name-brand drug; and

(4) if the enrollee's prescription benefit requires the use of generic-equivalent drugs (required generic) and the enrollee receives a name-brand drug when a generic equivalent is available, then the enrollee may be required to pay no more than the generic copayment plus the difference between the cost of the generic drug and the cost of the name-brand drug, even when the prescription is written "dispense as written."

(b) Pharmacy service must be available and accessible within the service area for the enrolled population through pharmacies licensed by the Texas State Board of Pharmacy. The HMO must offer the pharmacy services directly or through contracts.

Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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