Texas Insurance Code 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 § 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.
Terms Used In Texas Insurance Code 1369.056
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.