Sec. 1369.004. COVERAGE REQUIRED. (a) A health benefit plan that covers drugs must cover any drug prescribed to treat an enrollee for a chronic, disabling, or life-threatening illness covered under the plan if the drug: (1) has been approved by the United States Food and Drug Administration for at least one indication; and (2) is recognized by the following for treatment of the indication for which the drug is prescribed: (A) a prescription drug reference compendium approved by the commissioner for purposes of this section; or (B) substantially accepted peer-reviewed medical literature. (b) Coverage of a drug required under Subsection (a) must include coverage of medically necessary services associated with the administration of the drug. (c) A health benefit plan issuer may not, based on a "medical necessity" requirement, deny coverage of a drug required under Subsection (a) unless the reason for the denial is unrelated to the legal status of the drug use. (d) This section does not require a health benefit plan to cover: (1) experimental drugs that are not otherwise approved for an indication by the United States Food and Drug Administration; (2) any disease or condition that is excluded from coverage under the plan; or (3) a drug that the United States Food and Drug Administration has determined to be contraindicated for treatment of the current indication.
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