Texas Insurance Code 1369.0547 – Step Therapy Protocols for Prescription Drugs to Treat Serious Mental Illnesses
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(a) In this section, “serious mental illness” has the meaning assigned by § 1355.001.
(b) This section applies only to a drug prescribed to an enrollee who is 18 years of age or older to treat a diagnosis of a serious mental illness.
Terms Used In Texas Insurance Code 1369.0547
- Trial: A hearing that takes place when the defendant pleads "not guilty" and witnesses are required to come to court to give evidence.
- United States: includes a department, bureau, or other agency of the United States of America. See Texas Government Code 311.005
- Year: means 12 consecutive months. See Texas Government Code 311.005
(c) A health benefit plan that provides coverage for prescription drugs to treat a serious mental illness may not require, before the health benefit plan provides coverage of a prescription drug approved by the United States Food and Drug Administration, that the enrollee:
(1) fail to successfully respond to more than one different drug for each drug prescribed, excluding the generic or pharmaceutical equivalent of the prescribed drug; or
(2) prove a history of failure of more than one different drug for each drug prescribed, excluding the generic or pharmaceutical equivalent of the prescribed drug.
(d) Subject to § 1369.0546, a health benefit plan issuer may implement a step therapy protocol to require a trial of a generic or pharmaceutical equivalent of a prescribed prescription drug as a condition of continued coverage of the prescribed drug only:
(1) once in a plan year; and
(2) if the generic or pharmaceutical equivalent drug is added to the plan’s drug formulary.