Texas § 1369.056 ADVERSE DETERMINATION.

Texas Statutes

§ 1369.056 — ADVERSE DETERMINATION.

Texas § 1369.056

Code INInsurance Code

This text of Texas § 1369.056 (ADVERSE DETERMINATION.) is published on Counsel Stack Legal Research, covering Texas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook

Tex. Insurance Code Code Ann. § 1369.056 (2026).

Text

Sec. 1369.056. ADVERSE DETERMINATION.

(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 .

Free access — add to your briefcase to read the full text and ask questions with AI

Sec. 1369.056. ADVERSE DETERMINATION. (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 .

Legislative History

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005. Amended by: Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636 ), Sec. 2G.012, eff. April 1, 2009. Acts 2011, 82nd Leg., R.S., Ch. 501 (H.B. 1405 ), Sec. 7, eff. September 1, 2011.