# 28 Tex. Admin. Code § 21.3023: 28 TAC § 21.3023. Nonformulary Prescription Drugs; Adverse Determination, DIVISION 4. PRESCRIPTION DRUG FORMULARY COVERAGE AND DISCLOSURE REQUIREMENTS

> Texas · Regulations · In force

URL: https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C21_S21_3023

## Section

- **Citation:** 28 Tex. Admin. Code § 21.3023
- **Heading:** 28 TAC § 21.3023. Nonformulary Prescription Drugs; Adverse Determination, DIVISION 4. PRESCRIPTION DRUG FORMULARY COVERAGE AND DISCLOSURE REQUIREMENTS
- **Jurisdiction:** Texas
- **Kind:** Regulations
- **Status:** In force
- **Text as of:** August 14, 2026
- **Source:** Compiled text
- **Location:** Texas Administrative Code / Title 28 INSURANCE / Part 1 TEXAS DEPARTMENT OF INSURANCE / Chapter 21 TRADE PRACTICES / 28 TAC § 21.3023

## Text

If the issuer of a health benefit plan, its delegated entity,
 or its employees or agents refuses to provide coverage for a prescription
 drug that is not included in a drug formulary, and the enrollee's
 physician or other health care provider with prescriptive authority
 has determined the prescription drug is medically necessary to treat
 a condition covered by the enrollee's health benefit plan, the refusal
 to provide coverage for the prescription drug constitutes an adverse
 determination for the purpose of Insurance Code Chapter 4201. An enrollee
 may appeal the adverse determination under Insurance Code Chapter
 4201, Subchapters H and I, and the issuer of the health benefit plan,
 and its employees or agents, must review and resolve the appeal in
 accordance with those sections.

## Nearby sections

- [28 Tex. Admin. Code § 21.3001 28 TAC § 21.3001. Applicability and Severability, DIVISION 1. GENERAL PROVISIONS](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C21_S21_3001.md)
- [28 Tex. Admin. Code § 21.3002 28 TAC § 21.3002. Definitions; Pharmacy Identification Cards, DIVISION 2. IDENTIFICATION CARDS](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C21_S21_3002.md)
- [28 Tex. Admin. Code § 21.3003 28 TAC § 21.3003. Standard Identification Cards, DIVISION 2. IDENTIFICATION CARDS](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C21_S21_3003.md)
- [28 Tex. Admin. Code § 21.3004 28 TAC § 21.3004. Issuance of Standard Identification Cards, DIVISION 2. IDENTIFICATION CARDS](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C21_S21_3004.md)
- [28 Tex. Admin. Code § 21.3010 28 TAC § 21.3010. Definitions; Coverage of Off-Label Drugs, DIVISION 3. OFF-LABEL DRUGS](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C21_S21_3010.md)
- [28 Tex. Admin. Code § 21.3011 28 TAC § 21.3011. Minimum Standards of Coverage for Off-Label Drug Use, DIVISION 3. OFF-LABEL DRUGS](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C21_S21_3011.md)
- [28 Tex. Admin. Code § 21.3020 28 TAC § 21.3020. Definitions; Prescription Drug Formulary, DIVISION 4. PRESCRIPTION DRUG FORMULARY COVERAGE AND DISCLOSURE REQUIREMENTS](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C21_S21_3020.md)
- [28 Tex. Admin. Code § 21.3022 28 TAC § 21.3022. Continuation of Benefits, DIVISION 4. PRESCRIPTION DRUG FORMULARY COVERAGE AND DISCLOSURE REQUIREMENTS](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C21_S21_3022.md)
- [28 Tex. Admin. Code § 21.3023 28 TAC § 21.3023. Nonformulary Prescription Drugs; Adverse Determination, DIVISION 4. PRESCRIPTION DRUG FORMULARY COVERAGE AND DISCLOSURE REQUIREMENTS](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C21_S21_3023.md)
- [28 Tex. Admin. Code § 21.3030 28 TAC § 21.3030. Availability of Formulary Information, DIVISION 4. PRESCRIPTION DRUG FORMULARY COVERAGE AND DISCLOSURE REQUIREMENTS](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C21_S21_3030.md)
- [28 Tex. Admin. Code § 21.3031 28 TAC § 21.3031. Formulary Information for Individual Health Benefit Plans on Issuer's Website, DIVISION 4. PRESCRIPTION DRUG FORMULARY COVERAGE AND DISCLOSURE REQUIREMENTS](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C21_S21_3031.md)
- [28 Tex. Admin. Code § 21.3032 28 TAC § 21.3032. Formulary Disclosure Requirements for Individual Health Benefit Plans, DIVISION 4. PRESCRIPTION DRUG FORMULARY COVERAGE AND DISCLOSURE REQUIREMENTS](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C21_S21_3032.md)
- [28 Tex. Admin. Code § 21.3033 28 TAC § 21.3033. Facilitating Comparison Shopping for Individual Health Benefit Plans, DIVISION 4. PRESCRIPTION DRUG FORMULARY COVERAGE AND DISCLOSURE REQUIREMENTS](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C21_S21_3033.md)

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Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C21_S21_3023. Check the current official text before relying on it. Not legal advice.