79R7029 KCR-F
By: Armbrister S.B. No. 1324
A BILL TO BE ENTITLED
AN ACT
relating to the delivery of prescription drugs by mail order.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 1369, Insurance Code, as effective April
1, 2005, is amended by adding Subchapter E to read as follows:
SUBCHAPTER E. DELIVERY OF PRESCRIPTION DRUGS BY MAIL
Sec. 1369.201. DEFINITIONS. In this subchapter, "mail
order pharmacy" means a pharmacy that:
(1) does not have a retail facility in the community in
which an enrollee lives; and
(2) exclusively delivers prescription drugs to an
enrollee through the United States Postal Service or a commercial
delivery service.
Sec. 1369.202. APPLICABILITY OF SUBCHAPTER. (a) This
subchapter applies only to a health benefit plan that provides
benefits for medical or surgical expenses incurred as a result of a
health condition, accident, or sickness, including an individual,
group, blanket, or franchise insurance policy or insurance
agreement, a group hospital service contract, or an individual or
group evidence of coverage or similar coverage document that is
offered or administered by:
(1) an insurance company;
(2) a group hospital service corporation operating
under Chapter 842;
(3) a fraternal benefit society operating under
Chapter 885;
(4) a stipulated premium company operating under
Chapter 884;
(5) a reciprocal or interinsurance exchange operating
under Chapter 942;
(6) a health maintenance organization operating under
Chapter 843;
(7) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846;
(8) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844;
(9) a third-party administrator, including a pharmacy
benefit manager, that holds a certificate of authority under
Chapter 4151;
(10) the Teacher Retirement System of Texas under
Chapter 1575 or 1579; or
(11) the Employees Retirement System of Texas under
Chapter 1551.
(b) Notwithstanding any other law, this subchapter applies
to a standard health benefit plan issued under Chapter 1507 or
Article 3.80 or 20A.09N offered or administered by an entity
described by Subsection (a).
Sec. 1369.203. EXCEPTION. This subchapter does not apply
to:
(1) a health benefit plan that provides coverage:
(A) only for a specified disease or for another
limited benefit other than cancer;
(B) only for accidental death or dismemberment;
(C) for wages or payments in lieu of wages for a
period during which an employee is absent from work because of
sickness or injury;
(D) as a supplement to a liability insurance
policy;
(E) for credit insurance;
(F) only for dental or vision care; or
(G) only for indemnity for hospital confinement;
(2) a small employer health benefit plan written under
Chapter 1501;
(3) a Medicare supplemental policy as defined by
Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
(4) a workers' compensation insurance policy;
(5) medical payment insurance coverage provided under
an automobile insurance policy; or
(6) a long-term care insurance policy, including a
nursing home fixed indemnity policy, unless the commissioner
determines that the policy provides benefit coverage so
comprehensive that the policy is a health benefit plan as described
by Section 1369.151.
Sec. 1369.204. ACCESS TO PHARMACIES. (a) Notwithstanding
any other law, an issuer of a health benefit plan that provides
pharmacy benefits to enrollees may not:
(1) require an enrollee, as a condition of obtaining
benefits or reimbursement for prescription drugs or pharmacy
services, to obtain the drugs or services exclusively from a mail
order pharmacy;
(2) discriminate between different pharmacies based
on whether the pharmacy is a mail order pharmacy or a pharmacy
located in the community in which an enrollee lives by:
(A) limiting the quantity of a prescription drug
an enrollee may obtain from the pharmacy; or
(B) requiring an enrollee to pay a different
copayment, coinsurance, or deductible amount;
(3) provide a monetary incentive or impose a monetary
penalty on an enrollee that could reasonably be expected to affect
the enrollee's choice among pharmacies that have agreed to
participate in the health benefit plan; or
(4) prohibit a qualified pharmacy from participating
under the health benefit plan if the pharmacy meets all of the
conditions of and agrees to all of the terms of participation in the
health benefit plan.
(b) An issuer of a health benefit plan that provides
pharmacy benefits to enrollees shall offer all pharmacies the same
conditions and terms of participation in the health benefit plan,
regardless of whether a pharmacy is a mail order pharmacy or a
pharmacy located in the community in which an enrollee lives.
Sec. 1369.205. INJUNCTIVE RELIEF. An enrollee, pharmacy,
or pharmacist aggrieved by a violation or threatened violation of
this subchapter may file a civil cause of action requesting
injunctive relief to restrain an issuer of a health benefit plan
from committing a violation or threatened violation of this
subchapter.
SECTION 2. Section 1551.219, Insurance Code, as added by
Chapter 213, Acts of the 78th Legislature, Regular Session, 2003,
is amended to read as follows:
Sec. 1551.219. MAIL ORDER REQUIREMENT FOR PRESCRIPTION DRUG
COVERAGE PROHIBITED. The board of trustees or a health benefit plan
under this chapter that provides benefits for prescription drugs
may not require a participant in the group benefits program to
purchase a prescription drug through a mail order program. The
board or health benefit plan may not [shall] require that a
participant who chooses to obtain a prescription drug through a
retail pharmacy or other method other than by mail order pay a
deductible, copayment, coinsurance, or other cost-sharing
obligation to cover the additional cost of obtaining a prescription
drug through that method rather than by mail order.
SECTION 3. The change in law made this Act applies only to a
health benefit plan that is delivered, issued for delivery, or
renewed on or after January 1, 2006. A health benefit plan that is
delivered, issued for delivery, or renewed before January 1, 2006,
is covered by the law in effect at the time the policy was
delivered, issued for delivery, or renewed, and that law is
continued in effect for that purpose.
SECTION 4. This Act takes effect September 1, 2005.