Sec. 1369.056.  ADVERSE DETERMINATION.  (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:
(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.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by: 
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2G.012, eff. April 1, 2009.
Acts 2011, 82nd Leg., R.S., Ch. 501 (H.B. 1405), Sec. 7, eff. September 1, 2011.