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A BILL TO BE ENTITLED
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AN ACT
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relating to health benefit coverage for prescription drug |
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synchronization. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Chapter 1369, Insurance Code, is amended by |
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adding Subchapter H to read as follows: |
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SUBCHAPTER H. COVERAGE RELATED TO PRESCRIPTION DRUG |
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SYNCHRONIZATION |
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Sec. 1369.351. DEFINITIONS. In this subchapter: |
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(1) "Cost-sharing amount" includes an amount charged |
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for a deductible, coinsurance, or copayment. |
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(2) "Health care provider" means a person who provides |
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health care services under a license, certificate, registration, or |
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other similar evidence of regulation issued by this or another |
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state of the United States. |
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(3) "Physician" means an individual licensed to |
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practice medicine in this or another state of the United States. |
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Sec. 1369.352. APPLICABILITY OF SUBCHAPTER. (a) This |
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subchapter applies only to a health benefit plan that provides |
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benefits for medical or surgical expenses incurred as a result of a |
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health condition, accident, or sickness, including an individual, |
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group, blanket, or franchise insurance policy or insurance |
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agreement, a group hospital service contract, or an individual or |
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group evidence of coverage or similar coverage document that is |
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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 health maintenance organization operating under |
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Chapter 843; |
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(4) an approved nonprofit health corporation that |
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holds a certificate of authority under Chapter 844; |
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(5) a multiple employer welfare arrangement that holds |
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a certificate of authority under Chapter 846; |
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(6) a stipulated premium company operating under |
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Chapter 884; |
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(7) a fraternal benefit society operating under |
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Chapter 885; or |
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(8) an exchange operating under Chapter 942. |
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(b) Notwithstanding Section 172.014, Local Government Code, |
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or any other law, this subchapter applies to health and accident |
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coverage provided by a risk pool created under Chapter 172, Local |
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Government Code. |
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(c) This subchapter applies to group health coverage made |
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available by a school district in accordance with Section 22.004, |
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Education Code. |
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(d) Notwithstanding any provision in Chapter 1551, 1575, |
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1579, or 1601 or any other law, this subchapter applies to health |
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benefit plan coverage provided under: |
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(1) Chapter 1551; |
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(2) Chapter 1575; |
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(3) Chapter 1579; and |
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(4) Chapter 1601. |
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(e) Notwithstanding Section 1501.251 or any other law, this |
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subchapter applies to coverage under a small employer health |
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benefit plan subject to Chapter 1501. |
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(f) This subchapter applies to a consumer choice of benefits |
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plan issued under Chapter 1507. |
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(g) To the extent allowed by federal law, the child health |
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plan program operated under Chapter 62, Health and Safety Code, the |
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health benefits plan for children operated under Chapter 63, Health |
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and Safety Code, the state Medicaid program, and a managed care |
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organization that contracts with the Health and Human Services |
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Commission to provide health care services to Medicaid recipients |
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through a managed care plan shall provide the coverage required |
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under this subchapter to a recipient. |
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Sec. 1369.353. PRORATION OF COST-SHARING AMOUNT REQUIRED. |
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(a) A health benefit plan that provides benefits for prescription |
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drugs shall prorate any cost-sharing amount charged for a |
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prescription drug dispensed in a quantity that is less than a 30 |
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days' supply if: |
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(1) the pharmacy or the covered person's prescribing |
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physician or health care provider notifies the health benefit plan |
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that: |
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(A) the quantity dispensed is to synchronize the |
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dates that the pharmacy dispenses the covered person's prescription |
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drugs; and |
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(B) the synchronization of the dates is in the |
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best interest of the covered person; and |
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(2) the covered person agrees to the synchronization. |
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(b) The proration described by Subsection (a) must be based |
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on the number of days' supply of the drug actually dispensed. |
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Sec. 1369.354. PRORATION OF DISPENSING FEE PROHIBITED. A |
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health benefit plan that prorates a cost-sharing amount as required |
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by Section 1369.353 may not prorate the fee paid to the pharmacy for |
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dispensing the drug for which the cost-sharing amount was prorated. |
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Sec. 1369.355. IMPLEMENTATION OF PLAN. No individual or |
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group health insurance policy providing prescription drug coverage |
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shall deny coverage for the dispensing of a chronic medication that |
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is made in accordance with a plan among the health plan, individual |
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beneficiary or group plan, a practitioner and a pharmacist for the |
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purpose of synchronizing the filling or refilling of multiple |
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prescriptions for the insured. The individual or group health plan |
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must allow a pharmacy to override any denial codes indicating that a |
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prescription is being refilled too soon for the purposes of |
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medication synchronization. |
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SECTION 2. This Act applies only to a health benefit plan |
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that is delivered, issued for delivery, or renewed on or after |
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January 1, 2016. A health benefit plan delivered, issued for |
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delivery, or renewed before January 1, 2016, is governed by the law |
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as it existed immediately before the effective date of this Act, and |
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that law is continued in effect for that purpose. |
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SECTION 3. This Act takes effect September 1, 2015. |