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 .
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