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A BILL TO BE ENTITLED
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AN ACT
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relating to health benefit plan coverage of prescription drugs for |
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stage-four advanced, metastatic cancer. |
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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 E-1 to read as follows: |
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SUBCHAPTER E-1. COVERAGE OF PRESCRIPTION DRUGS FOR STAGE-FOUR |
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ADVANCED, METASTATIC CANCER |
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Sec. 1369.211. DEFINITION. In this subchapter, "stage-four |
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advanced, metastatic cancer" means cancer that has spread from the |
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primary or original site of the cancer to nearby tissues, lymph |
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nodes, or other areas or parts of the body. |
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Sec. 1369.212. 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 or pharmacy benefits |
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incurred as a result of a health condition, accident, or sickness, |
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including an individual, group, blanket, or franchise insurance |
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policy or insurance agreement, a group hospital service contract, |
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or an individual or group evidence of coverage or similar coverage |
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document that is issued 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; |
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(8) a Lloyd's plan operating under Chapter 941; or |
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(9) an exchange operating under Chapter 942. |
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(b) Notwithstanding any other law, this subchapter applies |
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to: |
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(1) a small employer health benefit plan subject to |
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Chapter 1501, including coverage provided through a health group |
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cooperative under Subchapter B of that chapter; |
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(2) a standard health benefit plan issued under |
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Chapter 1507; |
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(3) a basic coverage plan under Chapter 1551; |
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(4) a basic plan under Chapter 1575; |
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(5) a primary care coverage plan under Chapter 1579; |
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(6) a plan providing basic coverage under Chapter |
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1601; |
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(7) health benefits provided by or through a church |
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benefits board under Subchapter I, Chapter 22, Business |
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Organizations Code; |
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(8) group health coverage made available by a school |
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district in accordance with Section 22.004, Education Code; |
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(9) the state Medicaid program, including the Medicaid |
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managed care program operated under Chapter 533, Government Code; |
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(10) the child health plan program under Chapter 62, |
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Health and Safety Code; |
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(11) a regional or local health care program operated |
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under Section 75.104, Health and Safety Code; and |
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(12) a self-funded health benefit plan sponsored by a |
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professional employer organization under Chapter 91, Labor Code. |
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(c) This subchapter applies to coverage under a group health |
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benefit plan provided to a resident of this state regardless of |
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whether the group policy, agreement, or contract is delivered, |
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issued for delivery, or renewed in this state. |
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Sec. 1369.213. PROHIBITED CONDUCT. (a) A health benefit |
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plan that provides coverage for stage-four advanced, metastatic |
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cancer may not require, before the health benefit plan provides |
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coverage of a prescription drug approved by the United States Food |
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and Drug Administration, that the enrollee: |
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(1) fail to successfully respond to a different drug; |
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or |
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(2) prove a history of failure of a different drug. |
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(b) This section applies only to a drug the use of which is: |
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(1) consistent with best practices for the treatment |
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of stage-four advanced, metastatic cancer; and |
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(2) supported by peer-reviewed medical literature. |
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SECTION 2. This Act applies only to a health benefit plan |
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delivered, issued for delivery, or renewed on or after January 1, |
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2020. A health benefit plan delivered, issued for delivery, or |
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renewed before January 1, 2020, is governed by the law as it existed |
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immediately before the effective date of this Act, and that law is |
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continued in effect for that purpose. |
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SECTION 3. This Act takes effect September 1, 2019. |