| |
|
|
A BILL TO BE ENTITLED
|
|
|
AN ACT
|
| |
|
|
relating to health benefit plan coverage of prescription drugs for |
|
|
stage-four advanced, metastatic cancer. |
|
|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|
|
SECTION 1. Chapter 1369, Insurance Code, is amended by |
|
|
adding Subchapter E-1 to read as follows: |
|
|
SUBCHAPTER E-1. COVERAGE OF PRESCRIPTION DRUGS FOR STAGE-FOUR |
|
|
ADVANCED, METASTATIC CANCER |
|
|
Sec. 1369.211. DEFINITIONS. In this subchapter: |
|
|
(1) "Associated conditions" means the symptoms or side |
|
|
effects associated with stage-four advanced, metastatic cancer or |
|
|
its treatment and which, in the judgment of the health care |
|
|
practitioner, further jeopardize the health of a patient if left |
|
|
untreated. |
|
|
(2) "Stage-four advanced, metastatic cancer" means |
|
|
cancer that has spread from the primary or original site of the |
|
|
cancer to nearby tissues, lymph nodes, or other areas or parts of |
|
|
the body. |
|
|
Sec. 1369.212. APPLICABILITY OF SUBCHAPTER. (a) This |
|
|
subchapter applies only to a health benefit plan that provides |
|
|
benefits for medical or surgical expenses or pharmacy benefits |
|
|
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 an individual or group evidence of coverage or similar coverage |
|
|
document that is issued by: |
|
|
(1) an insurance company; |
|
|
(2) a group hospital service corporation operating |
|
|
under Chapter 842; |
|
|
(3) a health maintenance organization operating under |
|
|
Chapter 843; |
|
|
(4) an approved nonprofit health corporation that |
|
|
holds a certificate of authority under Chapter 844; |
|
|
(5) a multiple employer welfare arrangement that holds |
|
|
a certificate of authority under Chapter 846; |
|
|
(6) a stipulated premium company operating under |
|
|
Chapter 884; |
|
|
(7) a fraternal benefit society operating under |
|
|
Chapter 885; |
|
|
(8) a Lloyd's plan operating under Chapter 941; or |
|
|
(9) an exchange operating under Chapter 942. |
|
|
(b) Notwithstanding any other law, this subchapter applies |
|
|
to: |
|
|
(1) a small employer health benefit plan subject to |
|
|
Chapter 1501, including coverage provided through a health group |
|
|
cooperative under Subchapter B of that chapter; |
|
|
(2) a standard health benefit plan issued under |
|
|
Chapter 1507; |
|
|
(3) a basic coverage plan under Chapter 1551; |
|
|
(4) a basic plan under Chapter 1575; |
|
|
(5) a primary care coverage plan under Chapter 1579; |
|
|
(6) a plan providing basic coverage under Chapter |
|
|
1601; |
|
|
(7) health benefits provided by or through a church |
|
|
benefits board under Subchapter I, Chapter 22, Business |
|
|
Organizations Code; |
|
|
(8) group health coverage made available by a school |
|
|
district in accordance with Section 22.004, Education Code; |
|
|
(9) the state Medicaid program, including the Medicaid |
|
|
managed care program operated under Chapter 533, Government Code; |
|
|
(10) the child health plan program under Chapter 62, |
|
|
Health and Safety Code; |
|
|
(11) a regional or local health care program operated |
|
|
under Section 75.104, Health and Safety Code; and |
|
|
(12) a self-funded health benefit plan sponsored by a |
|
|
professional employer organization under Chapter 91, Labor Code. |
|
|
(c) This subchapter applies to coverage under a group health |
|
|
benefit plan provided to a resident of this state regardless of |
|
|
whether the group policy, agreement, or contract is delivered, |
|
|
issued for delivery, or renewed in this state. |
|
|
Sec. 1369.213. PROHIBITED CONDUCT. (a) A health benefit |
|
|
plan that provides coverage for stage-four advanced, metastatic |
|
|
cancer and associated conditions may not require, before the health |
|
|
benefit plan provides coverage of a prescription drug approved by |
|
|
the United States Food and Drug Administration, that the enrollee: |
|
|
(1) fail to successfully respond to a different drug; |
|
|
or |
|
|
(2) prove a history of failure of a different drug. |
|
|
(b) This section applies only to a drug the use of which is: |
|
|
(1) consistent with best practices for the treatment |
|
|
of stage-four advanced, metastatic cancer or an associated |
|
|
condition; and |
|
|
(2) supported by peer-reviewed medical literature. |
|
|
SECTION 2. This Act applies only to a health benefit plan |
|
|
delivered, issued for delivery, or renewed on or after January 1, |
|
|
2020. A health benefit plan delivered, issued for delivery, or |
|
|
renewed before January 1, 2020, is governed by the law as it existed |
|
|
immediately before the effective date of this Act, and that law is |
|
|
continued in effect for that purpose. |
|
|
SECTION 3. This Act takes effect September 1, 2019. |
|
|
|
|
|
* * * * * |