{"data":{"id":"us-tx/tex.-insurance-code-1369.056","jurisdiction":"us-tx","citation":"Tex. Insurance Code § 1369.056","heading":"ADVERSE DETERMINATION.","body":"(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:\n(1) the drug is not included in a drug formulary used by the health benefit plan; and\n(2) the enrollee's physician has determined that the drug is medically necessary.\n(b) The enrollee may appeal the adverse determination under Subchapters H and I, Chapter 4201.\nAdded by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.\nAmended by:\nActs 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2G.012, eff. April 1, 2009.\nActs 2011, 82nd Leg., R.S., Ch. 501 (H.B. 1405), Sec. 7, eff. September 1, 2011.","path":["INSURANCE CODE","TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES","SUBTITLE E. BENEFITS PAYABLE UNDER HEALTH COVERAGES","CHAPTER 1369. BENEFITS RELATED TO PRESCRIPTION DRUGS AND DEVICES AND RELATED SERVICES","SUBCHAPTER B. REQUIREMENTS AFFECTING COVERAGE OF SPECIFIC PRESCRIPTION DRUGS OR COST SHARING"],"source_url":"https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1369.htm#1369.056","current_through":"89th 2nd Called Legislative Session, 2025","vintage":"","retrieved_at":"2026-08-27T01:47:21Z","sha256":"8c9bc3981fdca36c13eb398ab7f714d7902d732ba0f6b785e9f47dd199e61ed2","source_id":"us-tx","stale":false,"prev":"us-tx/tex.-insurance-code-1369.055","next":"us-tx/tex.-insurance-code-1369.057"},"notice":"GroundRules: Original legal text. Not legal advice."}