SECTION 1. Chapter 1369,
Insurance Code, is amended by adding Subchapter F to read as follows:
SUBCHAPTER F. STANDARD
REQUEST FORM FOR PRIOR AUTHORIZATION OF PRESCRIPTION DRUG BENEFITS
Sec. 1369.251. DEFINITION.
In this subchapter, "prescription drug" has the meaning assigned
by Section 551.003, Occupations Code.
Sec. 1369.252. 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 a small or large employer
group contract or similar coverage document that is offered 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 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; or
(8) an approved nonprofit
health corporation that holds a certificate of authority under Chapter 844.
(b) This subchapter
applies to group health coverage made available by a school district in
accordance with Section 22.004, Education Code.
(c) Notwithstanding
Section 172.014, Local Government Code, or any other law, this subchapter
applies to health and accident coverage provided by a risk pool created
under Chapter 172, Local Government Code.
(d) Notwithstanding any
provision in Chapter 1551, 1575, 1579, or 1601 or any other law, this
subchapter applies to:
(1) a basic coverage plan
under Chapter 1551;
(2) a basic plan under
Chapter 1575;
(3) a primary care
coverage plan under Chapter 1579; and
(4) basic coverage under
Chapter 1601.
(f) Notwithstanding any
other law, this subchapter applies to coverage under:
(1) the child health plan
program under Chapter 62, Health and Safety Code, or the health benefits
plan for children under Chapter 63, Health and Safety Code; and
(2) the medical assistance
program under Chapter 32, Human Resources Code.
Sec. 1369.253. EXCEPTION. This
subchapter does not apply to:
(1) a health benefit plan
that provides coverage:
(A) only for a specified
disease or for another single benefit;
(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;
(G) only for hospital
expenses; or
(H) only for indemnity for
hospital confinement;
(2) a Medicare
supplemental policy as defined by Section 1882(g)(1), Social Security Act
(42 U.S.C. Section 1395ss);
(3) medical payment
insurance coverage provided under a motor vehicle insurance policy; or
(4) 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 1369.252.
(e) Notwithstanding any other law, this subchapter applies to medical
benefits provided to an injured employee under a workers'
compensation insurance policy or otherwise
under Title 5, Labor Code.
Sec. 1369.254. STANDARD
FORM. (a) The commissioner by rule shall:
(1) prescribe a single,
standard form for requesting prior authorization of prescription drug
benefits;
(2) require a health
benefit plan issuer or the agent of the health benefit plan issuer that
manages or administers prescription drug benefits to use the form for any
prior authorization of prescription drug benefits required by the plan;
(3) require that the
department and a health benefit plan issuer or the agent of the health benefit
plan issuer that manages or administers prescription drug benefits make the
form available electronically; and
(4) allow a completed form to be submitted electronically by the
prescribing provider to the health benefit plan issuer or the agent
of the health benefit plan issuer that manages or administers prescription
drug benefits.
(b) In prescribing a form
under this section, the commissioner shall:
(1) limit the form, as
printed, to not more than two pages;
(2) develop the form with
input from the advisory committee on uniform prior authorization forms
established under Section 1369.255; and
(3) take into
consideration:
(A) any form for
requesting prior authorization of benefits that is widely used in this
state or any form currently used by the department;
(B) request forms for
prior authorization of benefits established by the federal Centers for
Medicare and Medicaid Services; and
(C) national standards, or
draft standards, pertaining to electronic prior authorization of benefits.
Sec. 1369.255. ADVISORY
COMMITTEE ON UNIFORM PRIOR AUTHORIZATION FORMS. (a) The commissioner shall
appoint a committee to advise the commissioner on the technical,
operational, and practical aspects of developing the single, standard prior
authorization form required under Section 1369.254 for requesting prior
authorization of prescription drug benefits.
(b) The commissioner shall
consult the committee with respect to any rule relating to a subject
described by Section 1369.254 before adopting the rule.
(c) The committee shall be
composed of an equal number of members from each of the following groups:
(1) physicians;
(2) other prescribing
health care providers;
(3) hospitals;
(4) pharmacists;
(5) pharmacy benefit
managers; and
(6) health benefit plans.
(d) A member of the
advisory committee serves without compensation.
(e) Section 39.003(a) of
this code and Chapter 2110, Government Code, do not apply to the advisory
committee.
Sec. 1369.256. FAILURE TO
USE OR RESPOND TO STANDARD FORM. If a health benefit plan issuer or the
agent of the health benefit plan issuer that manages or administers
prescription drug benefits fails to use or accept the form prescribed under
this subchapter or fails to respond
within two business days of receipt to a completed form submitted by a
prescribing provider, the prior authorization is considered granted by the
health benefit plan.
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SECTION 1. Chapter 1369,
Insurance Code, is amended by adding Subchapter F to read as follows:
SUBCHAPTER F. STANDARD
REQUEST FORM FOR PRIOR AUTHORIZATION OF PRESCRIPTION DRUG BENEFITS
Sec. 1369.251. DEFINITION.
In this subchapter, "prescription drug" has the meaning assigned
by Section 551.003, Occupations Code.
Sec. 1369.252. 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 a small or large employer
group contract or similar coverage document that is offered 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 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; or
(8) an approved nonprofit
health corporation that holds a certificate of authority under Chapter 844.
(b) This subchapter
applies to group health coverage made available by a school district in
accordance with Section 22.004, Education Code.
(c) Notwithstanding
Section 172.014, Local Government Code, or any other law, this subchapter
applies to health and accident coverage provided by a risk pool created
under Chapter 172, Local Government Code.
(d) Notwithstanding any provision
in Chapter 1551, 1575, 1579, or 1601 or any other law, this subchapter
applies to:
(1) a basic coverage plan
under Chapter 1551;
(2) a basic plan under
Chapter 1575;
(3) a primary care
coverage plan under Chapter 1579; and
(4) basic coverage under Chapter
1601.
(e) Notwithstanding any
other law, this subchapter applies to coverage under:
(1) the child health plan
program under Chapter 62, Health and Safety Code, or the health benefits
plan for children under Chapter 63, Health and Safety Code; and
(2) the medical assistance
program under Chapter 32, Human Resources Code.
Sec. 1369.253. EXCEPTION. This
subchapter does not apply to:
(1) a health benefit plan
that provides coverage:
(A) only for a specified
disease or for another single benefit;
(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;
(G) only for hospital
expenses; or
(H) only for indemnity for
hospital confinement;
(2) a Medicare
supplemental policy as defined by Section 1882(g)(1), Social Security Act
(42 U.S.C. Section 1395ss);
(3) medical payment insurance
coverage provided under a motor vehicle insurance policy;
(4) 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 1369.252; or
(5) a workers'
compensation insurance policy.
Sec. 1369.254. STANDARD
FORM. (a) The commissioner by rule shall:
(1) prescribe a single,
standard form for requesting prior authorization of prescription drug
benefits;
(2) require a health
benefit plan issuer or the agent of the health benefit plan issuer that
manages or administers prescription drug benefits to use the form for any
prior authorization of prescription drug benefits required by the plan; and
(3) require that the
department and a health benefit plan issuer or the agent of the health
benefit plan issuer that manages or administers prescription drug benefits
make the form available electronically on the
website of:
(A) the department;
(B) the health benefit plan issuer; and
(C) the agent of the health benefit plan issuer.
(b) Not later than the second anniversary of the date national
standards for electronic prior authorization of benefits are adopted,
a health benefit plan issuer or the agent of the health benefit plan issuer
that manages or administers prescription drug benefits shall exchange prior authorization requests
electronically with a prescribing provider who has e-prescribing capability
and who initiates a request electronically.
(c) In prescribing a form
under this section, the commissioner shall:
(1) limit the form, as
printed, to not more than two pages;
(2) develop the form with
input from the advisory committee on uniform prior authorization forms
established under Section 1369.255; and
(3) take into
consideration:
(A) any form for
requesting prior authorization of benefits that is widely used in this
state or any form currently used by the department;
(B) request forms for
prior authorization of benefits established by the federal Centers for
Medicare and Medicaid Services; and
(C) national standards, or
draft standards, pertaining to electronic prior authorization of benefits.
Sec. 1369.255. ADVISORY
COMMITTEE ON UNIFORM PRIOR AUTHORIZATION FORMS. (a) The commissioner shall
appoint a committee to advise the commissioner on the technical,
operational, and practical aspects of developing the single, standard prior
authorization form required under Section 1369.254 for requesting prior
authorization of prescription drug benefits.
(b) The commissioner shall
consult the committee with respect to any rule relating to a subject
described by Section 1369.254 before adopting the rule and may consult the committee as needed with
respect to a subsequent amendment of an adopted rule.
(c) The committee shall be
composed of an equal number of members from each of the following groups:
(1) physicians;
(2) other prescribing
health care providers;
(3) hospitals;
(4) pharmacists;
(5) specialty pharmacies;
(6) pharmacy benefit managers;
(7) health benefit plan issuers for the Texas Health Insurance Pool
established under Chapter 1506;
(8) health benefit plan issuers; and
(9) health benefit plan networks of providers.
(d) A member of the
advisory committee serves without compensation.
(e) Section 39.003(a) of
this code and Chapter 2110, Government Code, do not apply to the advisory
committee.
Sec. 1369.256. FAILURE TO
USE OR ACKNOWLEDGE STANDARD FORM. If a health benefit plan issuer or the
agent of the health benefit plan issuer that manages or administers
prescription drug benefits fails to use or accept the form prescribed under
this subchapter or fails to acknowledge
within two business days the receipt of a completed form submitted by a
prescribing provider, the prior authorization is considered granted by the
health benefit plan.
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