BILL ANALYSIS |
C.S.S.B. 680 |
By: Hancock |
Insurance |
Committee Report (Substituted) |
BACKGROUND AND PURPOSE
Interested parties contend that health insurance carriers' exemption criteria with regard to prescription drug coverage and appeal procedures are not sufficiently consistent or accessible. C.S.S.B. 680 seeks to address this issue by applying certain reforms relating to step therapy protocols required by a health benefit plan in connection with prescription drug coverage.
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CRIMINAL JUSTICE IMPACT
It is the committee's opinion that this bill does not expressly create a criminal offense, increase the punishment for an existing criminal offense or category of offenses, or change the eligibility of a person for community supervision, parole, or mandatory supervision.
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RULEMAKING AUTHORITY
It is the committee's opinion that this bill does not expressly grant any additional rulemaking authority to a state officer, department, agency, or institution.
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ANALYSIS
C.S.S.B. 680 amends the Insurance Code to require a health benefit plan issuer that requires a step therapy protocol requiring 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 issuer provides coverage for the recommended prescription drug to establish, implement, and administer the step therapy protocol in accordance with clinical review criteria readily available to the health care industry. The bill requires the plan issuer to take into account the needs of atypical patient populations and diagnoses in establishing the clinical review criteria. The bill requires the clinical review criteria to consider generally accepted clinical practice guidelines that are developed and endorsed by a multidisciplinary panel of experts, based on high quality studies, research, and medical practice, created by an explicit and transparent process that meets certain criteria, and updated at appropriate intervals after a review of new evidence, research, and treatments. The bill authorizes the criteria to be based on peer‑reviewed publications developed by independent experts, which may include physicians, with expertise applicable to the relevant health condition if such clinical practice guidelines are not reasonably available. The bill prescribes the methods by which a multidisciplinary panel of experts composed of physicians and, as necessary, other health care providers that develops and endorses such clinical practice guidelines must manage conflicts of interest. The bill excepts from those methods 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 plan issuer or benefit manager regarding drugs or formularies.
C.S.S.B. 680 requires a health benefit plan issuer to 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 a step therapy protocol exception request may be submitted by the provider. The bill authorizes a prescribing provider on behalf of a patient to 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 and requires the provider to submit the request on the standard request form for prior authorization of prescription drug benefits prescribed by the commissioner of insurance. The bill specifies the circumstances under which a plan issuer is required to grant such a request.
C.S.S.B. 680 requires the standards adopted by the commissioner of insurance for independent review organizations to require each organization to make the organization's determination for a review of a step therapy protocol exception request within a certain timeframe and establishes that an exception request is considered granted if a health benefit plan issuer does not deny the request before 72 hours after the plan issuer receives the request. The bill establishes that an exception request that states the prescribing provider reasonably believes that denial of the request makes the death of or serious harm to the patient probable 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. The denial of an exception request is an adverse determination for purposes of statutory provisions relating to utilization review agents and is subject to appeal under those statutory provisions that relate to the appeal and independent review of an adverse determination. The bill entitles an adverse determination involving an exception request to an expedited appeal and requires the physician or, if appropriate, other health care provider deciding the appeal to consider atypical diagnoses and the needs of atypical patient populations.
C.S.S.B. 680 applies only to a health benefit plan that is delivered, issued for delivery, or renewed on or after January 1, 2018.
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EFFECTIVE DATE
September 1, 2017.
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COMPARISON OF SENATE ENGROSSED AND SUBSTITUTE
While C.S.S.B. 680 may differ from the engrossed in minor or nonsubstantive ways, the following comparison is organized and formatted in a manner that indicates the substantial differences between the engrossed and committee substitute versions of the bill.
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