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 and 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."

Source Note:The provisions of this §11.1605 adopted to be effective November 2, 1998, 23 TexReg 11347.