28 Tex. Admin. Code § 3.4205 - Contracts for Pharmaceutical Services
(a) An
insurer must apply the same administrative, financial and professional
conditions to all pharmacies and pharmacists participating or applying to
participate as contract providers under a health insurance policy.
(b) An insurer may establish additional
compensation or reimbursement rates for the following pharmaceutical services
or products as long as the rates are uniformly applied to pharmacies and
pharmacists participating as contract providers under a health insurance
policy:
(1) compounding as defined under the
Pharmacy Act, Texas Civil Statutes, Article 4542a-1, §5;
(2) dispensing of controlled substances as
defined under the Pharmacy Act, Texas Civil Statutes, Article 4542a-1, §5;
and
(3) preparing and dispensing
injectable drug therapies.
(c) In order to enhance accessibility to
pharmaceutical services, an insurer may establish additional compensation or
reimbursement rates for pharmaceutical services in counties with a population
of less than 40,000 (as determined by the most recent published findings from
the State Data Center of the Texas Department of Commerce) as long as the rates
are uniformly applied within each county to pharmacies and pharmacists
participating as contract providers under a health insurance policy.
(d) As an alternative to subsections (b) and
(c) of this section, an insurer may establish different terms and conditions,
including additional compensation and reimbursement rates for pharmaceutical
services, for the purpose of enhancing accessibility to pharmaceutical
services. A copy of the contract between the insurer and pharmacy or
pharmacist, which includes such terms and conditions, shall be filed with the
department and the insurer must demonstrate how the different terms and
conditions will enhance accessibility to pharmaceutical services. The terms and
conditions shall be disclosed to potential applicants in the application
process.
Notes
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