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A BILL TO BE ENTITLED
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AN ACT
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relating to the effect of certain reductions in a health benefit |
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plan enrollee's out-of-pocket expenses for certain prescription |
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drugs on enrollee cost-sharing requirements. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. The heading to Subchapter B, Chapter 1369, |
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Insurance Code, is amended to read as follows: |
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SUBCHAPTER B. REQUIREMENTS AFFECTING COVERAGE OF SPECIFIC |
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PRESCRIPTION DRUGS OR COST SHARING [SPECIFIED BY DRUG FORMULARY] |
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SECTION 2. Subchapter B, Chapter 1369, Insurance Code, is |
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amended by adding Section 1369.0542 to read as follows: |
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Sec. 1369.0542. EFFECT OF REDUCTIONS IN OUT-OF-POCKET |
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EXPENSES ON COST SHARING. (a) This section applies only to a |
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reduction in out-of-pocket expenses made by or on behalf of an |
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enrollee for a prescription drug covered by the enrollee's health |
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benefit plan for which: |
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(1) a generic equivalent does not exist; |
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(2) a generic equivalent does exist but the enrollee |
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has obtained access to the prescription drug under the enrollee's |
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health benefit plan using: |
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(A) a prior authorization process; |
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(B) a step therapy protocol; or |
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(C) the health benefit plan issuer's exceptions |
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and appeals process; |
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(3) an interchangeable biological product does not |
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exist; or |
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(4) an interchangeable biological product does exist |
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but the enrollee has obtained access to the prescription drug under |
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the enrollee's health benefit plan using: |
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(A) a prior authorization process; |
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(B) a step therapy protocol; or |
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(C) the health benefit plan issuer's exceptions |
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and appeals process. |
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(b) An issuer of a health benefit plan that covers |
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prescription drugs or a pharmacy benefit manager shall apply any |
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third-party payment, financial assistance, discount, product |
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voucher, or other reduction in out-of-pocket expenses made by or on |
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behalf of an enrollee for a prescription drug to the enrollee's |
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deductible, copayment, cost-sharing responsibility, or |
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out-of-pocket maximum applicable to health benefits under the |
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enrollee's plan. |
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SECTION 3. Section 1369.0542, Insurance Code, as added by |
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this Act, applies only to a health benefit plan that is delivered, |
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issued for delivery, or renewed on or after January 1, 2024. A |
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health benefit plan delivered, issued for delivery, or renewed |
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before January 1, 2024, is governed by the law as it existed |
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immediately before the effective date of this Act, and that law is |
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continued in effect for that purpose. |
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SECTION 4. This Act takes effect September 1, 2023. |