By Farabee H.B. No. 2495
76R7522 DLF-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to the use of a prescription drug formulary by a group
1-3 health benefit plan.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-6 amended by adding Article 21.52J to read as follows:
1-7 Art. 21.52J. USE OF PRESCRIPTION DRUG FORMULARY BY GROUP
1-8 HEALTH BENEFIT PLAN
1-9 Sec. 1. DEFINITION. In this article, "group health benefit
1-10 plan" means a health benefit plan described by Section 2 of this
1-11 article.
1-12 Sec. 2. SCOPE OF ARTICLE. (a) This article applies only to
1-13 a group health benefit plan that provides benefits for medical or
1-14 surgical expenses incurred as a result of a health condition,
1-15 accident, or sickness, including a group, blanket, or franchise
1-16 insurance policy or insurance agreement, a group hospital service
1-17 contract, or a group contract or similar coverage document that is
1-18 offered by:
1-19 (1) an insurance company;
1-20 (2) a group hospital service corporation operating
1-21 under Chapter 20 of this code;
1-22 (3) a fraternal benefit society operating under
1-23 Chapter 10 of this code;
1-24 (4) a stipulated premium insurance company operating
2-1 under Chapter 22 of this code;
2-2 (5) a reciprocal exchange operating under Chapter 19
2-3 of this code;
2-4 (6) a health maintenance organization operating under
2-5 the Texas Health Maintenance Organization Act (Chapter 20A,
2-6 Vernon's Texas Insurance Code);
2-7 (7) a multiple employer welfare arrangement that holds
2-8 a certificate of authority under Article 3.95-2 of this code; or
2-9 (8) an approved nonprofit health corporation that
2-10 holds a certificate of authority issued by the commissioner under
2-11 Article 21.52F of this code.
2-12 (b) This article does not apply to:
2-13 (1) a plan that provides coverage:
2-14 (A) only for a specified disease or other
2-15 limited benefit;
2-16 (B) only for accidental death or dismemberment;
2-17 (C) for wages or payments in lieu of wages for a
2-18 period during which an employee is absent from work because of
2-19 sickness or injury;
2-20 (D) as a supplement to liability insurance;
2-21 (E) for credit insurance;
2-22 (F) only for dental or vision care;
2-23 (G) only for hospital expenses; or
2-24 (H) only for indemnity for hospital confinement;
2-25 (2) a small employer health benefit plan written under
2-26 Chapter 26 of this code;
2-27 (3) a Medicare supplemental policy as defined by
3-1 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss),
3-2 as amended;
3-3 (4) workers' compensation insurance coverage;
3-4 (5) medical payment insurance coverage issued as part
3-5 of a motor vehicle insurance policy; or
3-6 (6) a long-term care policy, including a nursing home
3-7 fixed indemnity policy, unless the commissioner determines that the
3-8 policy provides benefit coverage so comprehensive that the policy
3-9 is a health benefit plan as described by Subsection (a) of this
3-10 section.
3-11 Sec. 3. CHANGES TO PRESCRIPTION DRUG FORMULARY; CONTINUATION
3-12 OF BENEFITS REQUIRED. (a) A group health benefit plan that covers
3-13 prescription drugs, uses a formulary to specify which prescription
3-14 drugs the plan will cover, and removes from its formulary a
3-15 prescription drug that the plan had previously included in the
3-16 formulary for a medical condition, shall continue to provide
3-17 benefits for the drug for an enrollee if the enrollee's prescribing
3-18 health care provider:
3-19 (1) prescribed the drug for the enrollee before the
3-20 drug was removed from the formulary; and
3-21 (2) continues to prescribe the drug for the same
3-22 condition.
3-23 (b) A group health benefit plan must continue to cover the
3-24 drug for the enrollee under Subsection (a) of this section until
3-25 the enrollee's plan renewal date.
3-26 Sec. 4. RULES. The commissioner may adopt rules to implement
3-27 this article.
4-1 SECTION 2. This Act takes effect September 1, 1999, and
4-2 applies only to a group health benefit plan that is delivered,
4-3 issued for delivery, or renewed on or after January 1, 2000. A
4-4 group health benefit plan delivered, issued for delivery, or
4-5 renewed before January 1, 2000, is governed by the law as it
4-6 existed immediately before the effective date of this Act, and that
4-7 law is continued in effect for that purpose.
4-8 SECTION 3. The importance of this legislation and the
4-9 crowded condition of the calendars in both houses create an
4-10 emergency and an imperative public necessity that the
4-11 constitutional rule requiring bills to be read on three several
4-12 days in each house be suspended, and this rule is hereby suspended.