SECTION 1. Section 1369.051,
Insurance Code, is amended by amending Subdivision (1) and adding
Subdivisions (1-a), (1-b), and (5) to read as follows:
(1) "Clinical
practice guideline" means a statement systematically developed by
health care providers to
assist a patient or health care provider in making a decision about
appropriate health care for a specific clinical circumstance or condition.
(1-a) "Clinical
review criteria" means the written screening procedures, decision
abstracts, clinical protocols, and practice guidelines used by a health
benefit plan issuer, utilization review organization, or independent review
organization to determine the medical necessity and appropriateness of a
health care service or prescription drug.
(1-b) "Drug
formulary" means a list of drugs:
(A) for which a health
benefit plan provides coverage;
(B) for which a health
benefit plan issuer approves payment; or
(C) that a health benefit
plan issuer encourages or offers incentives for physicians to prescribe.
(5) "Step therapy
protocol" means a protocol that requires an enrollee to use a
prescription drug or sequence of prescription drugs other than the drug
that the enrollee's physician recommends for the enrollee's treatment
before the health benefit plan provides coverage for the recommended drug.
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SECTION 1. Section 1369.051,
Insurance Code, is amended by amending Subdivision (1) and adding
Subdivisions (1-a), (1-b), and (5) to read as follows:
(1) "Clinical
practice guideline" means a statement systematically developed by a multidisciplinary panel of experts composed
of physicians and, as necessary, other health care providers to
assist a patient or health care provider in making a decision about
appropriate health care for a specific clinical circumstance or condition.
(1-a) "Clinical
review criteria" means the written screening procedures, decision
abstracts, clinical protocols, and clinical
practice guidelines used by a health benefit plan issuer, utilization
review organization, or independent review organization to determine the
medical necessity and appropriateness or
the experimental or investigational nature of a health care service
or prescription drug.
(1-b) "Drug formulary"
means a list of drugs:
(A) for which a health
benefit plan provides coverage;
(B) for which a health
benefit plan issuer approves payment; or
(C) that a health benefit
plan issuer encourages or offers incentives for physicians to prescribe.
(5) "Step therapy
protocol" means a protocol that requires an enrollee to use a
prescription drug or sequence of prescription drugs other than the drug
that the enrollee's physician recommends for the enrollee's treatment
before the health benefit plan provides coverage for the recommended drug.
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SECTION 2. Subchapter B,
Chapter 1369, Insurance Code, is amended by adding Sections 1369.0545 and
1369.0546 to read as follows:
Sec. 1369.0545. STEP
THERAPY PROTOCOLS. (a) A health benefit plan issuer that requires a step
therapy protocol before providing coverage for a prescription drug must
establish, implement, and administer the step therapy protocol in
accordance with clinical review criteria readily available to the health
care industry.
The clinical review
criteria must be based on:
(1) generally accepted
clinical practice guidelines that are:
(A) developed and
endorsed by a multidisciplinary panel of experts described by Subsection
(b); and
(B) based on high quality
studies, research, and medical practice that
are:
(i) created by an
explicit and transparent process that:
(a) minimizes bias and
conflicts of interest;
(b) explains the
relationship between treatment options and outcomes;
(c) rates the quality of
the evidence supporting the recommendations; and
(d) considers relevant
patient subgroups and preferences; and
(ii) updated at appropriate
intervals after a review of new evidence, research, and treatments; or
(2) if clinical practice
guidelines described by Subdivision (1) are not reasonably available,
peer-reviewed publications developed by independent experts with expertise
applicable to the relevant health condition.
(b) A multidisciplinary
panel of experts
that develops and endorses
clinical practice guidelines under Subsection (a)(1) must manage conflicts
of interest by:
(1) requiring each member
of the panel's writing or review group to:
(A) disclose any
potential conflict of interest, including a conflict of interest involving
an insurer, health benefit plan issuer, or pharmaceutical manufacturer; and
(B) recuse himself or
herself in any situation in which the member has a conflict of interest;
(2) using a methodologist
to work with writing groups to provide objectivity in data analysis and the
ranking of evidence by preparing evidence tables and facilitating
consensus; and
(3) offering an
opportunity for public review and comment.
(c) This section may not be construed to prohibit:
(1) a health benefit plan issuer from requiring a patient to
try an AB-rated generic equivalent drug before providing coverage for the
equivalent branded prescription drug; or
(2) a prescribing provider from prescribing a prescription drug
that is determined to be medically appropriate.
Sec. 1369.0546. STEP
THERAPY PROTOCOL EXCEPTION REQUESTS. (a) A health benefit plan issuer
shall establish a process in a user-friendly format that is readily
accessible to a patient or
prescribing provider
through which an exception
request under this section may be submitted by the provider.
(b) A prescribing
provider on behalf of a patient may submit to the patient's health benefit
plan issuer a written request for an exception to a step therapy protocol
required by the patient's health benefit plan. The commissioner by rule shall prescribe the form of the written
request.
(c) A health benefit plan
issuer shall grant a written request under Subsection (b) if the request
includes the prescribing provider's written statement stating that:
(1) the drug required
under the step therapy protocol:
(A) is contraindicated;
(B) will likely cause an
adverse reaction in or physical or mental harm to the patient; or
(C) is expected to be
ineffective based on the known clinical characteristics of the patient and
the known characteristics of the prescription drug regimen;
(2) the patient
previously discontinued taking the drug required under the step therapy
protocol, or another prescription drug in the same pharmacologic class or
with the same mechanism of action as the required drug, while under the
health benefit plan currently in force or while covered under another
health benefit plan because the drug was not effective or had a diminished
effect or because of an adverse event;
(3) the drug required
under the step therapy protocol is not in the best interest of the patient,
based on clinical appropriateness, because the patient's use of the drug is
expected to:
(A) cause a significant
barrier to the patient's adherence to or compliance with the patient's
plan of care;
(B) worsen a comorbid
condition of the patient; or
(C) decrease the
patient's ability to achieve or maintain reasonable functional ability in
performing daily activities; or
(4) the drug that is
subject to the step therapy protocol was prescribed for the patient's
condition while under the
health benefit plan
currently in force or a previous health benefit plan and the patient is
stable on the drug.
(d) Except as provided by
Subsection (e), if a health benefit plan issuer does not deny an exception
request described by Subsection (c) before 72 hours after the health
benefit plan issuer receives the request, the request is considered
granted.
(e) If an exception
request described by Subsection (c) also states that the prescribing
provider reasonably believes that denial of the request makes the death of
or serious harm to the patient probable, the request is considered granted
if the health benefit plan issuer does not deny the request before 24 hours
after the health benefit plan issuer receives the request.
(f) The denial of an
exception request under this section is an adverse determination for
purposes of Section 4201.002 and is subject to appeal under Subchapters H
and I, Chapter 4201.
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SECTION 2. Subchapter B,
Chapter 1369, Insurance Code, is amended by adding Sections 1369.0545 and
1369.0546 to read as follows:
Sec. 1369.0545. STEP
THERAPY PROTOCOLS. (a) A health benefit plan issuer that requires a step
therapy protocol before providing coverage for a prescription drug must
establish, implement, and administer the step therapy protocol in
accordance with clinical review criteria readily available to the health
care industry. The health benefit plan
issuer shall take into account the needs of atypical patient populations
and diagnoses in establishing the clinical review criteria. The
clinical review criteria:
(1) must consider generally accepted clinical
practice guidelines that are:
(A) developed and
endorsed by a multidisciplinary panel of experts described by Subsection
(b);
(B) based on high quality
studies, research, and medical practice;
(C) created by an
explicit and transparent process that:
(i) minimizes bias and
conflicts of interest;
(ii) explains the
relationship between treatment options and outcomes;
(iii) rates the quality
of the evidence supporting the recommendations; and
(iv) considers relevant
patient subgroups and preferences; and
(D) updated at
appropriate intervals after a review of new evidence, research, and
treatments; or
(2) if clinical practice
guidelines described by Subdivision (1) are not reasonably available, may be based on peer-reviewed
publications developed by independent experts, which may include physicians, with expertise applicable
to the relevant health condition.
(b) A multidisciplinary
panel of experts composed of physicians
and, as necessary, other health care providers that develops and
endorses clinical practice guidelines under Subsection (a)(1) must manage
conflicts of interest by:
(1) requiring each member
of the panel's writing or review group to:
(A) disclose any
potential conflict of interest, including a conflict of interest involving
an insurer, health benefit plan issuer, or pharmaceutical manufacturer; and
(B) recuse himself or
herself in any situation in which the member has a conflict of interest;
(2) using a methodologist
to work with writing groups to provide objectivity in data analysis and the
ranking of evidence by preparing evidence tables and facilitating
consensus; and
(3) offering an
opportunity for public review and comment.
(c) Subsection (b) does not apply to a panel or committee of
experts, including a pharmacy and therapeutics committee, established by a
health benefit plan issuer or a pharmacy benefit manager that advises the
health benefit plan issuer or pharmacy benefit manager regarding drugs or
formularies.
Sec. 1369.0546. STEP
THERAPY PROTOCOL EXCEPTION REQUESTS. (a) A health benefit plan issuer
shall establish a process in a user-friendly format that is readily
accessible to a patient and
prescribing provider, in the health
benefit plan's formulary document and otherwise, through which an
exception request under this section may be submitted by the provider.
(b) A prescribing
provider on behalf of a patient may submit to the patient's health benefit
plan issuer a written request for an exception to a step therapy protocol
required by the patient's health benefit plan. The provider shall submit the request on the standard form
prescribed by the commissioner under Section 1369.304.
(c) A health benefit plan
issuer shall grant a written request under Subsection (b) if the request
includes the prescribing provider's written statement, with supporting documentation, stating
that:
(1) the drug required
under the step therapy protocol:
(A) is contraindicated;
(B) will likely cause an
adverse reaction in or physical or mental harm to the patient; or
(C) is expected to be
ineffective based on the known clinical characteristics of the patient and
the known characteristics of the prescription drug regimen;
(2) the patient
previously discontinued taking the drug required under the step therapy
protocol, or another prescription drug in the same pharmacologic class or
with the same mechanism of action as the required drug, while under the
health benefit plan currently in force or while covered under another
health benefit plan because the drug was not effective or had a diminished
effect or because of an adverse event;
(3) the drug required
under the step therapy protocol is not in the best interest of the patient,
based on clinical appropriateness, because the patient's use of the drug is
expected to:
(A) cause a significant
barrier to the patient's adherence to or compliance with the patient's plan
of care;
(B) worsen a comorbid
condition of the patient; or
(C) decrease the
patient's ability to achieve or maintain reasonable functional ability in
performing daily activities; or
(4)(A) the drug that is
subject to the step therapy protocol was prescribed for the patient's
condition;
(B) the patient:
(i) received benefits for the drug under the health
benefit plan currently in force or a previous health benefit plan; and
(ii) is stable on the
drug; and
(C) the change in the patient's prescription drug regimen
required by the step therapy protocol is expected to be ineffective or
cause harm to the patient based on the known clinical characteristics of
the patient and the known characteristics of the required prescription drug
regimen.
(d) Except as provided by
Subsection (e), if a health benefit plan issuer does not deny an exception request
described by Subsection (c) before 72 hours after the health benefit plan
issuer receives the request, the request is considered granted.
(e) If an exception
request described by Subsection (c) also states that the prescribing
provider reasonably believes that denial of the request makes the death of
or serious harm to the patient probable, the request is considered granted
if the health benefit plan issuer does not deny the request before 24 hours
after the health benefit plan issuer receives the request.
(f) The denial of an
exception request under this section is an adverse determination for
purposes of Section 4201.002 and is subject to appeal under Subchapters H
and I, Chapter 4201.
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SECTION 5. Section 4202.003,
Insurance Code, is amended to read as follows:
Sec. 4202.003. REQUIREMENTS
REGARDING TIMELINESS OF DETERMINATION. (a)
Except as provided by Subsection (b), the [The] standards
adopted under Section 4202.002 must require each independent review
organization to make the organization's determination:
(1) for a life-threatening
condition as defined by Section 4201.002 or the provision of prescription
drugs or intravenous infusions for which the patient is receiving benefits
under the health insurance policy,
not later than the earlier of
the third day after the date the organization receives the information
necessary to make the determination or, with respect to:
(A) a review of a health
care service provided to a person with a life-threatening condition
eligible for workers' compensation medical benefits, the eighth day after
the date the organization receives the request that the determination be
made; or
(B) a review of a health
care service other than a service described by Paragraph (A), the third day
after the date the organization receives the request that the determination
be made; or
(2) for a situation other
than a situation described by Subdivision (1), not later than the earlier
of:
(A) the 15th day after the
date the organization receives the information necessary to make the
determination; or
(B) the 20th day after the
date the organization receives the request that the determination be made.
(b) For a review of a step therapy protocol exception request
under Section 1369.0546, the standards adopted under Section 4202.002 must
require each independent review organization to make the organization's
determination not later than:
(1) except as provided by Subdivision (2), 72 hours after the
organization receives the request that the determination be made; or
(2) for a determination of an exception request described by
Section 1369.0546(e), 24 hours after the organization receives the request
that the determination be made.
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SECTION 4. Section 4202.003,
Insurance Code, is amended to read as follows:
Sec. 4202.003. REQUIREMENTS
REGARDING TIMELINESS OF DETERMINATION.
The standards adopted under
Section 4202.002 must require each independent review organization to make
the organization's determination:
(1) for a life-threatening
condition as defined by Section 4201.002, [or] the provision
of prescription drugs or intravenous infusions for which the patient is
receiving benefits under the health insurance policy, or a review of a step therapy protocol exception
request under Section 1369.0546,
not later than the earlier of the third day after the date the organization
receives the information necessary to make the determination or, with
respect to:
(A) a review of a health
care service provided to a person with a life-threatening condition
eligible for workers' compensation medical benefits, the eighth day after
the date the organization receives the request that the determination be
made; or
(B) a review of a health
care service other than a service described by Paragraph (A), the third day
after the date the organization receives the request that the determination
be made; or
(2) for a situation other
than a situation described by Subdivision (1), not later than the earlier
of:
(A) the 15th day after the
date the organization receives the information necessary to make the determination;
or
(B) the 20th day after the
date the organization receives the request that the determination be made.
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