1-1 By: Madla S.B. No. 804
1-2 (In the Senate - Filed February 20, 2001; February 21, 2001,
1-3 read first time and referred to Committee on Business and Commerce;
1-4 March 26, 2001, reported adversely, with favorable Committee
1-5 Substitute by the following vote: Yeas 6, Nays 0; March 26, 2001,
1-6 sent to printer.)
1-7 COMMITTEE SUBSTITUTE FOR S.B. No. 804 By: Shapleigh
1-8 A BILL TO BE ENTITLED
1-9 AN ACT
1-10 relating to continuation of benefits for prescription drugs under
1-11 certain group health benefit plans.
1-12 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-13 SECTION 1. Section 3, Article 21.52J, Insurance Code, is
1-14 amended to read as follows:
1-15 Sec. 3. DISCLOSURE OF DRUG FORMULARY REQUIRED. A group
1-16 health benefit plan that covers prescription drugs and that uses
1-17 one or more drug formularies to specify which prescription drugs
1-18 the plan will cover shall:
1-19 (1) provide to each enrollee in plain language in the
1-20 coverage documentation provided to the enrollee:
1-21 (A) notice that the plan uses one or more drug
1-22 formularies;
1-23 (B) an explanation of what a drug formulary is;
1-24 (C) a statement regarding the method the plan
1-25 uses to determine which prescription drugs are included in or
1-26 excluded from a drug formulary;
1-27 (D) a statement of how often the plan reviews
1-28 the contents of each drug formulary; [and]
1-29 (E) notice that the enrollee may contact the
1-30 plan to find out if a specific drug is on a particular drug
1-31 formulary; and
1-32 (F) a statement of the enrollee's right to
1-33 complain in a circumstance in which benefits for a drug are denied
1-34 because the drug is not included in the plan's drug formulary,
1-35 including the enrollee's rights under Section 4(c) of this article;
1-36 (2) disclose to any individual on request, not later
1-37 than the third business day after the date of the request, whether
1-38 a specific drug is on a particular drug formulary; and
1-39 (3) notify an enrollee or any other individual who
1-40 requests information about a drug formulary under this section that
1-41 the presence of a drug on a drug formulary does not guarantee that
1-42 an enrollee's health care provider will prescribe that drug for a
1-43 particular medical condition or mental illness.
1-44 SECTION 2. Section 4, Article 21.52J, Insurance Code, is
1-45 amended by amending Subsection (a) and adding Subsections (c) and
1-46 (d) to read as follows:
1-47 (a) Except as provided by Subsection (d), a [A] group health
1-48 benefit plan that offers prescription drug benefits shall make a
1-49 prescription drug that, at the beginning of the plan year, was
1-50 included on the health benefit plan's drug formulary [approved or
1-51 covered for a medical condition or mental illness] available to an
1-52 [each] enrollee at the contracted benefit level for that
1-53 prescription drug until the enrollee's plan renewal date,
1-54 regardless of whether the prescribed drug has been removed from the
1-55 health benefit plan's drug formulary, if:
1-56 (1) the drug was at any time previously prescribed to
1-57 the enrollee and provided under the plan, regardless of whether the
1-58 drug was prescribed during that plan year; or
1-59 (2) the enrollee can demonstrate, in accordance with
1-60 Subsection (c) of this section, that the drug was at any time
1-61 previously prescribed to the enrollee.
1-62 (c) An enrollee who is denied benefits for a prescription
1-63 drug because the drug has been removed from the group health
1-64 benefit plan's drug formulary during a plan year and who believes
2-1 the benefits are required under Subsection (a)(2) of this section
2-2 may file a complaint in accordance with the complaint procedures of
2-3 the group health benefit plan. On an initial showing by the
2-4 enrollee that the drug was previously prescribed at any time to the
2-5 enrollee, the group health benefit plan shall provide the benefits
2-6 at the contracted benefit level from the date the benefits were
2-7 initially requested until the enrollee's plan renewal date. An
2-8 initial showing under this subsection may be made by any means that
2-9 demonstrates that a prescription drug was previously prescribed to
2-10 an enrollee, including a copy of a prescription or a letter or
2-11 other appropriate documentation from the physician who prescribed
2-12 the drug or pharmacist who distributed the drug.
2-13 (d) Subsection (a) of this section does not require a group
2-14 health benefit plan to continue to provide prescription drug
2-15 benefits for a prescription drug if:
2-16 (1) the United States Food and Drug Administration
2-17 prohibits:
2-18 (A) the sale or use of the drug; or
2-19 (B) the use of the drug as prescribed to an
2-20 enrollee; or
2-21 (2) the United States Food and Drug Administration or
2-22 the drug's manufacturer identifies a side effect, adverse reaction,
2-23 or other health risk associated with the drug that:
2-24 (A) was unknown at the time the drug was
2-25 prescribed to the enrollee; or
2-26 (B) is substantially more severe, as determined
2-27 under rules adopted by the commissioner, than was believed at the
2-28 time the drug was prescribed to the enrollee.
2-29 SECTION 3. Section 6, Article 21.52J, Insurance Code, is
2-30 amended to read as follows:
2-31 Sec. 6. RULES. The commissioner may adopt rules to
2-32 implement this article, including rules governing documents or
2-33 other evidence that must be accepted under Section 4(c) of this
2-34 article by a group health benefit plan as an initial showing that a
2-35 drug was at any time previously prescribed to an enrollee.
2-36 SECTION 4. This Act takes effect September 1, 2001, and
2-37 applies only to a group health benefit plan that is delivered,
2-38 issued for delivery, or renewed on or after January 1, 2002. A
2-39 group health benefit plan that is delivered, issued for delivery,
2-40 or renewed before January 1, 2002, is governed by the law as it
2-41 existed immediately before the effective date of this Act, and that
2-42 law is continued in effect for this purpose.
2-43 * * * * *