(a) The formulary information required by §21.3032 of this title (relating to Formulary Disclosure Requirements for Individual Health Benefit Plans) must include a summary titled "Summary of Formulary Benefits" that includes this statement: "The information in this document is designed to help you understand the prescription drug benefits offered under this plan and to compare these benefits to those offered by other plans. Information contained in this summary is designed to help you compare both the value and scope of formulary benefits." The summary must also include, in the following order:
  (1) Under the header, "How to Find Information on the Cost of Prescription Drugs," a description of how a consumer may use the plan's summary health plan document, formulary information, and web-based tool, if applicable, to determine the cost sharing they may owe, and an explanation that cost-sharing information reflects a consumer's share of the cost excluding any deductible requirement, calculated using an estimate of the full price of the drug, which is based on the plan's median or the actual cost allowed amount at a given point in time.
  (2) Under the header, "Formulary by Health Benefit Plan," a chart that displays each formulary that applies to each individual health benefit plan issued by the issuer and includes a direct electronic link to the Summary of Benefits and Coverage for each individual health plan listed. This chart may be limited to individual health benefit plans being sold in the market in which the applicable health benefit plan is issued.
  (3) Under the header, "Drugs by Cost-Sharing Tier," if the drug formulary is a multitier formulary, a summary that displays the percent of drugs in each cost-sharing tier for all drugs in the formulary.
  (4) Under the header, "How Prescription Drugs are Covered under the Plan":
    (A) under a section titled, "Formulary Composition," an explanation of the method the issuer uses to determine the prescription drugs to be included in or excluded from the formulary, an explanation of whether the formulary is open or closed, and a statement of how often the issuer reviews the contents of the formulary.
    (B) Under a section titled, "Right to Appeal," an explanation that if a drug is not covered under the formulary, but the enrollee's physician has determined that the drug is medically necessary, the consumer has the right to appeal, consistent with §21.3023 of this title (relating to Nonformulary Prescription Drugs; Adverse Determination) and Insurance Code §1369.056. A statement of how cost sharing will be determined for drugs covered as a result of a successful appeal.
    (C) Under a section titled, "Continuation of Coverage," an explanation of a consumer's right to continued coverage for a prescription drug at the coverage level or tier at which the drug was covered at the beginning of the plan year, until the enrollee's plan renewal date, consistent with §21.3022 of this title (relating to Continuation of Benefits) and Insurance Code §1369.055 and §1369.0541.
    (D) Under a section titled, "Off-Label Drug Use," an explanation of how formulary drugs are covered under the plan, including an explanation of coverage for off-label drug use.
    (E) Under a section titled, "Cost Sharing," an explanation of how cost sharing is determined under the plan, including whether a deductible applies to prescription drug coverage; how cost sharing for prescription drugs counts towards the plan's deductible; how drugs are categorized into each of the formulary tiers or cost-sharing levels, whether the drug formulary is a multitier formulary; the difference between preferred and nonpreferred drugs, if applicable; the difference in coverage for drugs dispensed from in-network and out-of-network pharmacies; and the difference in coverage for drugs dispensed in a retail pharmacy and a mail-order pharmacy, if applicable.
    (F) Under a section titled, "Medical Management Requirements," an explanation of each type of medical management requirement used by the individual health benefit plan, including prior authorization, step therapy, or other protocol requirements that limit access to prescription drugs, as applicable.
(b) Formulary information must include the summary information required under subsection (a) of this section beginning on the first page of the formulary document under the title, "Summary of Formulary Benefits."

Source Note: The provisions of this §21.3033 adopted to be effective August 18, 2016, 41 TexReg 6035; amended to be effective May 21, 2018, 43 TexReg 3243