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 21.3031 - Formulary Information for Individual Health Benefit Plans on Issuer's Website

Universal Citation: 28 TX Admin Code § 21.3031

Current through Reg. 50, No. 26; June 27, 2025

(a) Except as permitted under subsection (c) of this section, an issuer of an individual health benefit plan must display the formulary information required under § 21.3032 and § 21.3033 of this title (relating to Formulary Disclosure Requirements for Individual Health Benefit Plans and Facilitating Comparison Shopping for Individual Health Benefit Plans) on a website that is publicly accessible to enrollees, prospective enrollees, and others without requiring the use of paid software, a password, user name, or personally identifiable information. The formulary information must:

(1) be electronically searchable by drug name; and

(2) use at least 10-point font.

(b) Each summary health plan document must include a direct electronic link to the website that contains the formulary information. The direct electronic link must deliver the user directly to the formulary information associated with the health benefit plan described by the health plan document, without requiring additional navigation or user input.

(c) As an alternative to displaying the information required under § 21.3032(c) of this title, alongside the formulary information required generally under subsection (a) of this section, an individual health benefit plan issuer may elect to make plan-specific cost-sharing information available through a web-based tool. A direct electronic link to the web-based tool must be included on each page of the formulary disclosure that lists each drug. The purpose of this alternative method is to encourage the provision of the most timely and accurate drug price information. In order to qualify for this alternative method, a web-based tool must:

(1) be publicly accessible to enrollees, prospective enrollees, and others without requiring the use of paid software or the necessity of a password, user name, or personally identifiable information;

(2) allow consumers to electronically search formulary information by the name under which the health benefit plan is marketed;

(3) include the following plan-specific cost-sharing information for each drug:
(A) whether the drug is subject to a pharmacy or medical deductible and where the deductible may be found;

(B) the full price of the drug, based on the plan's median allowed amount or the actual cost for the drug using the most up-to-date data available, and a statement as to whether the price is based on the median or the actual cost;

(C) the cost-sharing amount the enrollee will owe for each drug under the pharmacy or medical benefit in a retail, mail order, or physician- or practitioner-administered setting, if applicable, excluding any deductible requirement, including as applicable:
(i) the dollar amount of a copayment; and

(ii) for a drug subject to coinsurance, the dollar amount of cost sharing the enrollee will owe, calculated based on the full price of the drug and the cost-sharing parameters under the enrollee's health benefit plan for the tier under which the drug is assigned; and

(4) include, prominently displayed on the web page under the header "Formulary by Health Benefit Plan," a direct electronic link to a chart that displays each formulary that applies to each individual health benefit plan issued by the issuer and includes a direct electronic link to the Summary of Benefits and Coverage and formulary document for each health plan listed. This chart may be limited to health benefit plans being sold in the market in which the applicable health benefit plan is issued.

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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