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