SECTION 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.

Source Note: The provisions of this §3.4205 adopted to be effective December 25, 1996, 21 TexReg 11947; transferred effective April 16, 1999, 24 TexReg 3092.