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A BILL TO BE ENTITLED
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AN ACT
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relating to provision by a health benefit plan of prescription drug |
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coverage specified by formulary. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 1369.051(2), Insurance Code, is amended |
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to read as follows: |
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(2) "Enrollee" means an individual who is covered |
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under a [group] health benefit plan, including a covered dependent. |
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SECTION 2. Section 1369.052, Insurance Code, is amended to |
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read as follows: |
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Sec. 1369.052. APPLICABILITY OF SUBCHAPTER. This |
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subchapter applies only to a [group] health benefit plan that |
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provides benefits for medical or surgical expenses incurred as a |
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result of a health condition, accident, or sickness, including an |
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individual, [a] group, blanket, or franchise insurance policy or |
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insurance agreement, a group hospital service contract, or a small |
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or large employer group contract or similar coverage document that |
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is offered by: |
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(1) an insurance company; |
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(2) a group hospital service corporation operating |
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under Chapter 842; |
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(3) a fraternal benefit society operating under |
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Chapter 885; |
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(4) a stipulated premium company operating under |
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Chapter 884; |
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(5) a reciprocal exchange operating under Chapter 942; |
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(6) a health maintenance organization operating under |
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Chapter 843; |
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(7) a multiple employer welfare arrangement that holds |
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a certificate of authority under Chapter 846; or |
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(8) an approved nonprofit health corporation that |
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holds a certificate of authority under Chapter 844. |
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SECTION 3. Section 1369.053, Insurance Code, is amended to |
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read as follows: |
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Sec. 1369.053. EXCEPTION. This subchapter does not apply |
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to: |
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(1) a health benefit plan that provides coverage: |
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(A) only for a specified disease or for another |
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single benefit; |
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(B) only for accidental death or dismemberment; |
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(C) for wages or payments in lieu of wages for a |
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period during which an employee is absent from work because of |
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sickness or injury; |
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(D) as a supplement to a liability insurance |
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policy; |
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(E) for credit insurance; |
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(F) only for dental or vision care; |
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(G) only for hospital expenses; or |
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(H) only for indemnity for hospital confinement; |
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(2) [a small employer health benefit plan written
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under Chapter 1501;
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[(3)] a Medicare supplemental policy as defined by |
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Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss), |
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as amended; |
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(3) [(4)] a workers' compensation insurance policy; |
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(4) [(5)] medical payment insurance coverage provided |
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under a motor vehicle insurance policy; or |
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(5) [(6)] a long-term care insurance policy, including |
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a nursing home fixed indemnity policy, unless the commissioner |
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determines that the policy provides benefit coverage so |
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comprehensive that the policy is a health benefit plan as described |
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by Section 1369.052. |
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SECTION 4. Section 1369.054, Insurance Code, is amended to |
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read as follows: |
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Sec. 1369.054. NOTICE AND DISCLOSURE OF CERTAIN INFORMATION |
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REQUIRED. An issuer of a [group] health benefit plan that covers |
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prescription drugs and uses one or more drug formularies to specify |
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the prescription drugs covered under the plan shall: |
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(1) provide in plain language in the coverage |
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documentation provided to each enrollee: |
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(A) notice that the plan uses one or more drug |
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formularies; |
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(B) an explanation of what a drug formulary is; |
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(C) a statement regarding the method the issuer |
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uses to determine the prescription drugs to be included in or |
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excluded from a drug formulary; |
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(D) a statement of how often the issuer reviews |
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the contents of each drug formulary; and |
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(E) notice that an enrollee may contact the |
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issuer to determine whether a specific drug is included in a |
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particular drug formulary; |
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(2) disclose to an individual on request, not later |
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than the third business day after the date of the request, whether a |
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specific drug is included in a particular drug formulary; and |
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(3) notify an enrollee and any other individual who |
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requests information under this section that the inclusion of a |
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drug in a drug formulary does not guarantee that an enrollee's |
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health care provider will prescribe that drug for a particular |
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medical condition or mental illness. |
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SECTION 5. Section 1369.055, Insurance Code, is amended to |
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read as follows: |
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Sec. 1369.055. CONTINUATION OF COVERAGE REQUIRED; OTHER |
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DRUGS NOT PRECLUDED. (a) An issuer of a [group] health benefit plan |
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that covers prescription drugs shall offer to each enrollee at the |
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contracted benefit level and until the enrollee's plan renewal date |
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any prescription drug that was approved or covered under the plan |
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for a medical condition or mental illness, regardless of whether |
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the drug has been removed from the health benefit plan's drug |
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formulary before the plan renewal date. |
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(b) This section does not prohibit a physician or other |
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health professional who is authorized to prescribe a drug from |
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prescribing a drug that is an alternative to a drug for which |
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continuation of coverage is required under Subsection (a) if the |
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alternative drug is: |
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(1) covered under the [group] health benefit plan; and |
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(2) medically appropriate for the enrollee. |
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SECTION 6. Section 1369.056(a), Insurance Code, is amended |
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to read as follows: |
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(a) The refusal of a [group] health benefit plan issuer to |
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provide benefits to an enrollee for a prescription drug is an |
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adverse determination for purposes of Section 4201.002 if: |
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(1) the drug is not included in a drug formulary used |
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by the [group] health benefit plan; and |
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(2) the enrollee's physician has determined that the |
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drug is medically necessary. |
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SECTION 7. The change in law made by this Act applies only |
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to a health benefit plan delivered, issued for delivery, or renewed |
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on or after January 1, 2012. A health benefit plan delivered, |
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issued for delivery, or renewed before January 1, 2012, is governed |
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by the law in effect immediately before the effective date of this |
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Act, and that law is continued in effect for that purpose. |
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SECTION 8. This Act takes effect September 1, 2011. |