A health benefit plan must set up a process to approve certain medication synchronization plans and must cover covered medications dispensed under those plans.
Sec. 1369.456. IMPLEMENTATION OF CERTAIN MEDICATION SYNCHRONIZATION PLANS. (a) For the purposes of this section: (1) "Chronic illness" means an illness or physical condition that may be: (A) reasonably expected to continue for an uninterrupted period of at least three months; and (B) controlled but not cured by medical treatment. (2) "Medication synchronization plan" means a plan established for the purpose of synchronizing the filling or refilling of multiple prescriptions. (b) A health benefit plan shall establish a process through which the following parties may jointly approve a medication synchronization plan for medication to treat an enrollee's chronic illness: (1) the health benefit plan; (2) the enrollee; (3) the prescribing physician or health care provider; and (4) a pharmacist. (c) A health benefit plan shall provide coverage for a medication dispensed in accordance with the dates established in the medication synchronization plan described by Subsection (b). (d) A health benefit plan shall establish a process that allows a pharmacist or pharmacy to override the health benefit plan's denial of coverage for a medication described by Subsection (b). (e) A health benefit plan shall allow a pharmacist or pharmacy to override the health benefit plan's denial of coverage through the process described by Subsection (d), and the health benefit plan shall provide coverage for the medication if: (1) the prescription for the medication is being refilled in accordance with the medication synchronization plan described by Subsection (b); and (2) the reason for the denial is that the prescription is being refilled before the date established by the plan's general prescription refill guidelines. Added by Acts 2017, 85th Leg., R.S., Ch. 1007 (H.B. 1296), Sec. 1, eff. September 1, 2017. SUBCHAPTER K. PRESCRIPTION DRUG COST TRANSPARENCY