Sec. 1369.056. ADVERSE DETERMINATION

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(a) The refusal of a health benefit plan issuer to provide benefits to an enrollee for a prescription drug is an adverse determination for purposes of Section 4201.002 if:
(1) the drug is not included in a drug formulary used by the health benefit plan; and
(2) the enrollee's physician has determined that the drug is medically necessary.
(b) The enrollee may appeal the adverse determination under Subchapters H and I, Chapter 4201.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005. Amended by: Acts 2007, 80th Leg., R.S., Ch. 730 , Sec. 2G.012, eff. April 1, 2009. Acts 2011, 82nd Leg., R.S., Ch. 501 , Sec. 7, eff. September 1, 2011.

                    
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