Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 21 - TRADE PRACTICES
Subchapter V - PHARMACY BENEFITS
Division 4 - PRESCRIPTION DRUG FORMULARY COVERAGE AND DISCLOSURE REQUIREMENTS
Section 21.3023 - Nonformulary Prescription Drugs; Adverse Determination

If the issuer of a health benefit plan, its delegated entity, or their employees or agents refuses to provide coverage for a prescription drug that is not included in a drug formulary, and the enrollee's physician or other health care provider with prescriptive authority has determined the prescription drug is medically necessary to treat a condition covered by the enrollee's health benefit plan, the refusal to provide coverage for the prescription drug constitutes an adverse determination for the purpose of Insurance Code Chapter 4201 . An enrollee may appeal the adverse determination under Insurance Code Chapter 4201, Subchapters H and I, and the issuer of the health benefit plan, and its employees or agents, must review and resolve the appeal in accordance with those sections.