1. (a) Should an HMO provide prescription drug coverage, such coverage shall be subject to copayments for both generic drugs and name brand drugs. If the negotiated or usual or customary cost of the drug is less than the copayment, the enrollee shall pay the lower cost. The copayments may be the same, or if different, shall be applied as follows:

   1. (1) if the prescription is for a generic drug, the enrollee shall pay no more than the generic copayment;

   2. (2) if the prescription is for a name brand drug, the enrollee shall pay no more than the name brand copayment if:

      1. (A) the prescription is written "Dispense as written"; or
      2. (B) there is no generic equivalent for the prescribed drug;
   3. (3) if the prescription is written "product selection permitted" and the enrollee elects to receive a name brand drug when a generic equivalent is available, the enrollee shall pay no more than the generic copayment plus the difference between the cost of the generic drug and the cost of the name brand drug.
   4. (4) if the enrollee's prescription benefit requires the use of generic equivalent drugs ("required generic") and the enrollee receives a name brand drug when a generic equivalent is available, the enrollee shall pay no more than the generic copayment plus the difference between the cost of the generic drug and the cost of the name brand drug, even when the prescription is written "dispense as written."
2. (b) Pharmacy services, if offered, shall be available and accessible within the service area for the enrolled population through pharmacies licensed by the Texas State Board of Pharmacy. The HMO shall offer such pharmacy services directly or through contracts.
3. (c) An HMO that provides coverage for prescription drugs under an individual or group health benefit plan, except small employer health benefit plans as defined by the Insurance Code §1501.002, shall comply with the requirements of the Insurance Code Chapter 1369 Subchapter A and §21.3010 and §21.3011 of this title (relating to Definitions; Coverage of Off-Label Drugs and Minimum Standards of Coverage for Off-Label Drug Use).
4. (d) An HMO that provides coverage for prescription drugs or devices under an individual or group state-mandated health benefit plan shall comply with the requirements of the Insurance Code Chapter 1369 Subchapter C (Coverage of Prescription Contraceptive Drugs and Devices and Related Services).
5. (e) An HMO that provides coverage for prescription drugs under a group state-mandated health benefit plan and that utilizes one or more drug formularies to specify which prescription drugs the plan will cover shall comply with the requirements of the Insurance Code Chapter 1369 Subchapter B and §§21.3020 - 21.3023 of this title (relating to Definitions; Prescription Drug Formulary, Required Disclosure of Drug Formulary, Continuation of Benefits, and Nonformulary Prescription Drugs; Adverse Determination).

Source Note:The provisions of this §11.1605 adopted to be effective November 2, 1998, 23 TexReg 11347; amended to be effective February 24, 2005, 30 TexReg 854; amended to be effective November 15, 2006, 31 TexReg 9298.