Tex. Insurance Code § 1369.004
COVERAGE REQUIRED
Texas · Texas Insurance Code · Status: effective
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- Citation
- Tex. Insurance Code § 1369.004, COVERAGE REQUIRED, Texas, version 1 as recorded 2026-07-09, yourstate.us, https://yourstate.us/provision/682152
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Full text
(a) A health benefit plan that covers drugs must cover any drug prescribed to treat an enrollee for a chronic, disabling, or life-threatening illness covered under the plan if the drug:
(1) has been approved by the United States Food and Drug Administration for at least one indication; and
(2) is recognized by the following for treatment of the indication for which the drug is prescribed:
(A) a prescription drug reference compendium approved by the commissioner for purposes of this section; or
(B) substantially accepted peer-reviewed medical literature.
(b) Coverage of a drug required under Subsection (a) must include coverage of medically necessary services associated with the administration of the drug.
(c) A health benefit plan issuer may not, based on a "medical necessity" requirement, deny coverage of a drug required under Subsection (a) unless the reason for the denial is unrelated to the legal status of the drug use.
(d) This section does not require a health benefit plan to cover:
(1) experimental drugs that are not otherwise approved for an indication by the United States Food and Drug Administration;
(2) any disease or condition that is excluded from coverage under the plan; or
(3) a drug that the United States Food and Drug Administration has determined to be contraindicated for treatment of the current indication.