New Texas Prescription Drug Information Requirement

Beginning with the 2025 policy year, Senate Bill 622 requires Texas carriers to make prescription drug benefit information available upon request to members and providers in real time. The required information includes cost sharing, drug lists, utilization management requirements, and other coverage details. It applies to insured medical plans in Texas and not to self-funded medical or drug programs (other than those offered by professional employer organizations).

Summary:

A carrier must provide information regarding a covered prescription drug to an enrollee or the enrollee's prescribing provider on request. The information provided must include the carrier's drug formulary and, for the prescription drug and any formulary alternative:

1. the enrollee's eligibility;
2. cost-sharing information, including any deductible, copayment, or coinsurance, which must:
   • be consistent with cost-sharing requirements under the enrollee's plan;
   • be accurate at the time the cost-sharing information is provided; and
   • include any variance in cost-sharing based on the patient's preferred dispensing retail or mail-order pharmacy or the prescribing provider; and
3. applicable utilization management requirements.

The carrier must:

1. respond in real time to a request made through a standard Application Programming Interface (API);
2. allow the use of an integrated technology or service as necessary to provide the required information;
3. ensure that the information provided is current no later than one business day after the date a change is made; and
4. provide the information if the request is made using the drug's unique billing code and National Drug Code.

A carrier may not restrict a prescribing provider from communicating to the enrollee information about the cash price of the drug, or any additional information on any lower cost or clinically appropriate alternative drug, whether or not the drug is covered under the enrollee's plan.

This requirement is effective beginning with a policy year beginning on or after January 1, 2025.

Employer Action

Employers with insured medical plans written out of Texas should be aware of the above change. No employer action is required.