# Tex. Insurance Code § 1369.004: COVERAGE REQUIRED

> Texas · Statutes · In force

URL: https://www.frixlaw.com/law-library/statutes/STATE_TX_Cin_C1369_S1369.004

## Section

- **Citation:** Tex. Insurance Code § 1369.004
- **Heading:** COVERAGE REQUIRED
- **Jurisdiction:** Texas
- **Kind:** Statutes
- **Status:** In force
- **Text as of:** August 14, 2026
- **Source:** Compiled text
- **Location:** TX Code / Code in / Chapter 1369 / Section 1369.004

## Text

(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.

## Nearby sections

- [Tex. Insurance Code § 1369.001 § 1369.001. DEFINITIONS.](https://www.frixlaw.com/law-library/statutes/STATE_TX_Cin_C1369_S1369.001.md)
- [Tex. Insurance Code § 1369.002 § 1369.002. APPLICABILITY OF SUBCHAPTER.](https://www.frixlaw.com/law-library/statutes/STATE_TX_Cin_C1369_S1369.002.md)
- [Tex. Insurance Code § 1369.003 § 1369.003. EXCEPTION.](https://www.frixlaw.com/law-library/statutes/STATE_TX_Cin_C1369_S1369.003.md)
- [Tex. Insurance Code § 1369.004 § 1369.004. COVERAGE REQUIRED.](https://www.frixlaw.com/law-library/statutes/STATE_TX_Cin_C1369_S1369.004.md)
- [Tex. Insurance Code § 1369.005 § 1369.005. RULES.](https://www.frixlaw.com/law-library/statutes/STATE_TX_Cin_C1369_S1369.005.md)
- [Tex. Insurance Code § 1369.0041 § 1369.0041. CERTAIN PAYMENTS AND REFILLS.](https://www.frixlaw.com/law-library/statutes/STATE_TX_Cin_C1369_S1369.0041.md)
- [Tex. Insurance Code § 1369.051 § 1369.051. DEFINITIONS.](https://www.frixlaw.com/law-library/statutes/STATE_TX_Cin_C1369_S1369.051.md)
- [Tex. Insurance Code § 1369.052 § 1369.052. APPLICABILITY OF SUBCHAPTER.](https://www.frixlaw.com/law-library/statutes/STATE_TX_Cin_C1369_S1369.052.md)
- [Tex. Insurance Code § 1369.053 § 1369.053. EXCEPTION.](https://www.frixlaw.com/law-library/statutes/STATE_TX_Cin_C1369_S1369.053.md)
- [Tex. Insurance Code § 1369.054 § 1369.054. NOTICE AND DISCLOSURE OF CERTAIN INFORMATION REQUIRED.](https://www.frixlaw.com/law-library/statutes/STATE_TX_Cin_C1369_S1369.054.md)
- [Tex. Insurance Code § 1369.055 § 1369.055. CONTINUATION OF COVERAGE REQUIRED; OTHER DRUGS NOT PRECLUDED.](https://www.frixlaw.com/law-library/statutes/STATE_TX_Cin_C1369_S1369.055.md)
- [Tex. Insurance Code § 1369.056 § 1369.056. ADVERSE DETERMINATION.](https://www.frixlaw.com/law-library/statutes/STATE_TX_Cin_C1369_S1369.056.md)
- [Tex. Insurance Code § 1369.057 § 1369.057. RULES.](https://www.frixlaw.com/law-library/statutes/STATE_TX_Cin_C1369_S1369.057.md)
- [Tex. Insurance Code § 1369.076 § 1369.076. DEFINITIONS.](https://www.frixlaw.com/law-library/statutes/STATE_TX_Cin_C1369_S1369.076.md)

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Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_TX_Cin_C1369_S1369.004. Check the current official text before relying on it. Not legal advice.