New Texas Prescription Drug Information Requirement

Overview

Beginning with the 2025 policy year, Senate Bill 622 requires Texas carriers to provide prescription drug benefit information in real time upon request to members and providers. This includes details such as cost sharing, drug lists, utilization management requirements, and other coverage information. These requirements apply to insured medical plans in Texas and exclude self-funded medical or drug programs, except those offered by professional employer organizations.

Key Requirements

  • Information Provided: Carriers must supply the following upon request for a covered prescription drug and any formulary alternative:

    1. The enrollee’s eligibility.

    2. Cost-sharing details, including deductible, copayment, or coinsurance, which must:

      • Be consistent with the enrollee’s plan requirements.

      • Be accurate at the time of the request.

      • Reflect variances in cost-sharing based on the enrollee’s pharmacy preference (retail or mail-order) or prescribing provider.

    3. Applicable utilization management requirements.

  • Real-Time Access: Carriers must:

    1. Respond to requests in real time via a standard Application Programming Interface (API).

    2. Use integrated technology or services to provide required information.

    3. Ensure information is updated within one business day of any changes.

    4. Provide information using the drug's unique billing code and National Drug Code.

  • Prescriber Communication: Carriers cannot restrict prescribing providers from sharing the drug’s cash price or information about lower-cost or clinically appropriate alternatives, even if not covered under the enrollee’s plan.

Effective Date

This requirement applies to policy years beginning on or after January 1, 2025.

Employer Action

Employers with insured medical plans written in Texas should be aware of this change. No specific action is required on their part.

Dexter Dible