By: Madla S.B. No. 804
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to continuation of benefits for prescription drugs under
1-3 certain group health benefit plans.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Section 3, Article 21.52J, Insurance Code, is
1-6 amended to read as follows:
1-7 Sec. 3. DISCLOSURE OF DRUG FORMULARY REQUIRED. A group
1-8 health benefit plan that covers prescription drugs and that uses
1-9 one or more drug formularies to specify which prescription drugs
1-10 the plan will cover shall:
1-11 (1) provide to each enrollee in plain language in the
1-12 coverage documentation provided to the enrollee:
1-13 (A) notice that the plan uses one or more drug
1-14 formularies;
1-15 (B) an explanation of what a drug formulary is;
1-16 (C) a statement regarding the method the plan
1-17 uses to determine which prescription drugs are included in or
1-18 excluded from a drug formulary;
1-19 (D) a statement of how often the plan reviews
1-20 the contents of each drug formulary; [and]
1-21 (E) notice that the enrollee may contact the
1-22 plan to find out if a specific drug is on a particular drug
1-23 formulary; and
1-24 (F) a statement of the enrollee's right to
1-25 complain in a circumstance in which benefits for a drug are denied
2-1 because the drug is not included in the plan's drug formulary,
2-2 including the enrollee's rights under Section 4(c) of this article;
2-3 (2) disclose to any individual on request, not later
2-4 than the third business day after the date of the request, whether
2-5 a specific drug is on a particular drug formulary; and
2-6 (3) notify an enrollee or any other individual who
2-7 requests information about a drug formulary under this section that
2-8 the presence of a drug on a drug formulary does not guarantee that
2-9 an enrollee's health care provider will prescribe that drug for a
2-10 particular medical condition or mental illness.
2-11 SECTION 2. Section 4, Article 21.52J, Insurance Code, is
2-12 amended by amending Subsection (a) and adding Subsections (c) and
2-13 (d) to read as follows:
2-14 (a) Except as provided by Subsection (d), a [A] group health
2-15 benefit plan that offers prescription drug benefits shall make a
2-16 prescription drug that, at the beginning of the plan year, was
2-17 included on the health benefit plan's drug formulary [approved or
2-18 covered for a medical condition or mental illness] available to an
2-19 [each] enrollee at the contracted benefit level for that
2-20 prescription drug until the enrollee's plan renewal date,
2-21 regardless of whether the prescribed drug has been removed from the
2-22 health benefit plan's drug formulary, if:
2-23 (1) the drug was at any time previously prescribed to
2-24 the enrollee and provided under the plan, regardless of whether the
2-25 drug was prescribed during that plan year; or
2-26 (2) the enrollee can demonstrate, in accordance with
3-1 Subsection (c) of this section, that the drug was at any time
3-2 previously prescribed to the enrollee.
3-3 (c) An enrollee who is denied benefits for a prescription
3-4 drug because the drug has been removed from the group health
3-5 benefit plan's drug formulary during a plan year and who believes
3-6 the benefits are required under Subsection (a)(2) of this section
3-7 may file a complaint in accordance with the complaint procedures of
3-8 the group health benefit plan. On an initial showing by the
3-9 enrollee that the drug was previously prescribed at any time to the
3-10 enrollee, the group health benefit plan shall provide the benefits
3-11 at the contracted benefit level from the date the benefits were
3-12 initially requested until the enrollee's plan renewal date. An
3-13 initial showing under this subsection may be made by any means that
3-14 demonstrates that a prescription drug was previously prescribed to
3-15 an enrollee, including a copy of a prescription or a letter or
3-16 other appropriate documentation from the physician who prescribed
3-17 the drug or pharmacist who distributed the drug.
3-18 (d) Subsection (a) of this section does not require a group
3-19 health benefit plan to continue to provide prescription drug
3-20 benefits for a prescription drug if:
3-21 (1) the United States Food and Drug Administration
3-22 prohibits:
3-23 (A) the sale or use of the drug; or
3-24 (B) the use of the drug as prescribed to an
3-25 enrollee; or
3-26 (2) the United States Food and Drug Administration or
4-1 the drug's manufacturer identifies a side effect, adverse reaction,
4-2 or other health risk associated with the drug that:
4-3 (A) was unknown at the time the drug was
4-4 prescribed to the enrollee; or
4-5 (B) is substantially more severe, as determined
4-6 under rules adopted by the commissioner, than was believed at the
4-7 time the drug was prescribed to the enrollee.
4-8 SECTION 3. Section 6, Article 21.52J, Insurance Code, is
4-9 amended to read as follows:
4-10 Sec. 6. RULES. The commissioner may adopt rules to
4-11 implement this article, including rules governing documents or
4-12 other evidence that must be accepted under Section 4(c) of this
4-13 article by a group health benefit plan as an initial showing that a
4-14 drug was at any time previously prescribed to an enrollee.
4-15 SECTION 4. This Act takes effect September 1, 2001, and
4-16 applies only to a group health benefit plan that is delivered,
4-17 issued for delivery, or renewed on or after January 1, 2002. A
4-18 group health benefit plan that is delivered, issued for delivery,
4-19 or renewed before January 1, 2002, is governed by the law as it
4-20 existed immediately before the effective date of this Act, and that
4-21 law is continued in effect for this purpose.