| (a) Prescription drug coverage that includes copayments
must do so for both generic drugs and name-brand drugs. If the negotiated
or usual and customary cost of the drug is less than the copayment,
the enrollee may only be required to pay the lower cost. The copayments
may be the same, or if different, must be applied as follows:
(1) if the prescription is for a generic drug, the
enrollee may be required to pay no more than the generic copayment;
(2) if the prescription is for a name-brand drug, the
enrollee may be required to pay no more than the name-brand copayment
if:
(A) the prescription is written "dispense as written";
or
(B) there is no generic equivalent for the prescribed
drug;
(3) if the prescription is written "product selection
permitted" and the enrollee elects to receive a name-brand drug when
a generic equivalent is available, then the enrollee may be required
to pay no more than the generic copayment plus the difference between
the cost of the generic drug and the cost of the name-brand drug;
and
(4) if the enrollee's prescription benefit requires
the use of generic-equivalent drugs (required generic) and the enrollee
receives a name-brand drug when a generic equivalent is available,
then the enrollee may be required to pay no more than the generic
copayment plus the difference between the cost of the generic drug
and the cost of the name-brand drug, even when the prescription is
written "dispense as written."
(b) Pharmacy service must be available and accessible
within the service area for the enrolled population through pharmacies
licensed by the Texas State Board of Pharmacy. The HMO must offer
the pharmacy services directly or through contracts.
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