Sec. 1369.259.  CALCULATION OF RECOUPMENT; USE OF EXTRAPOLATION PROHIBITED.  (a)  A health benefit plan issuer or pharmacy benefit manager may not calculate the amount of a recoupment based on:
(1)  an absence of documentation the pharmacist or pharmacy is not required by applicable federal laws and regulations and state laws and rules to maintain; or
(2)  an error that does not result in actual financial harm to the patient or enrollee, the health benefit plan issuer, or the pharmacy benefit manager.
(b)  A health benefit plan issuer or pharmacy benefit manager may not require extrapolation audits as a condition of participation in a contract, network, or program for a pharmacist or pharmacy.
(c)  A health benefit plan issuer or pharmacy benefit manager may not use extrapolation to complete an on-site audit or a desk audit of a pharmacist or pharmacy.  Notwithstanding Subsection (a)(2), the amount of a recoupment must be based on the actual overpayment or underpayment and may not be based on an extrapolation.
(d)  A health benefit plan issuer or pharmacy benefit manager may not include a dispensing fee amount in the calculation of an overpayment unless:
(1)  the fee was a duplicate charge;
(2)  the prescription for which the fee was charged:
(A)  was not dispensed; or
(B)  was dispensed:
(i)  without the prescriber's authorization;
(ii)  to the wrong patient; or
(iii)  with the wrong instructions; or
(3)  the wrong drug was dispensed.
Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.