86R3299 SMT-F
 
  By: Campbell S.B. No. 580
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to modification of certain prescription drug benefits and
  coverage offered by certain health benefit plans.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 1369.0541, Insurance Code, is amended by
  amending Subsections (a) and (b) and adding Subsections (a-1) and
  (b-1) to read as follows:
         (a)  Except as provided by Section 1369.055(a-1) and
  Subsection (b-1) of this section, a [A] health benefit plan issuer
  may modify drug coverage provided under a health benefit plan if:
               (1)  the modification occurs at the time of coverage
  renewal;
               (2)  the modification is effective uniformly among all
  group health benefit plan sponsors covered by identical or
  substantially identical health benefit plans or all individuals
  covered by identical or substantially identical individual health
  benefit plans, as applicable; and
               (3)  not later than the 60th day before the date the
  modification is effective, the issuer provides written notice of
  the modification to the commissioner, each affected group health
  benefit plan sponsor, each affected enrollee in an affected group
  health benefit plan, and each affected individual health benefit
  plan holder.
         (a-1)  The notice described by Subsection (a)(3) must
  include a statement:
               (1)  indicating that the health benefit plan issuer is
  modifying drug coverage provided under the health benefit plan;
               (2)  explaining the type of modification; and
               (3)  indicating that, on renewal of the health benefit
  plan, the health benefit plan issuer may not modify an enrollee's
  contracted benefit level for any prescription drug that was
  approved or covered under the plan in the immediately preceding
  plan year as provided by Section 1369.055(a-1).
         (b)  Modifications affecting drug coverage that require
  notice under Subsection (a) include:
               (1)  removing a drug from a formulary;
               (2)  adding a requirement that an enrollee receive
  prior authorization for a drug;
               (3)  imposing or altering a quantity limit for a drug;
               (4)  imposing a step-therapy restriction for a drug;
  [and]
               (5)  moving a drug to a higher cost-sharing tier;
               (6)  increasing a coinsurance, copayment, deductible,
  or other out-of-pocket expense that an enrollee must pay for a drug;
  and
               (7)  reducing the maximum drug coverage amount [unless
  a generic drug alternative to the drug is available].
         (b-1)  Modifications affecting drug coverage that are more
  favorable to enrollees may be made at any time and do not require
  notice under Subsection (a), including:
               (1)  the addition of a drug to a formulary;
               (2)  the reduction of a coinsurance, copayment,
  deductible, or other out-of-pocket expense that an enrollee must
  pay for a drug; and
               (3)  the removal of a utilization review requirement.
         SECTION 2.  Section 1369.055, Insurance Code, is amended by
  adding Subsections (a-1) and (a-2) to read as follows:
         (a-1)  On renewal of a health benefit plan, the plan issuer
  may not modify an enrollee's contracted benefit level for any
  prescription drug that was approved or covered under the plan in the
  immediately preceding plan year and prescribed during that year for
  a medical condition or mental illness of the enrollee if:
               (1)  the enrollee was covered by the health benefit
  plan on the date immediately preceding the renewal date;
               (2)  a physician or other prescribing provider
  appropriately prescribes the drug for the medical condition or
  mental illness;
               (3)  the prescribing provider in consultation with the
  enrollee determines that the drug is the most appropriate course of
  treatment; and
               (4)  the drug is considered safe and effective for
  treating the enrollee's medical condition or mental illness.
         (a-2)  Modifications prohibited under Subsection (a-1)
  include:
               (1)  removing a drug from a formulary;
               (2)  adding a requirement that an enrollee receive
  prior authorization for a drug;
               (3)  imposing or altering a quantity limit for a drug;
               (4)  imposing a step-therapy restriction for a drug;
  and
               (5)  moving a drug to a higher cost-sharing tier.
         SECTION 3.  The changes in law made by this Act apply only to
  a health benefit plan that is 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 4.  This Act takes effect September 1, 2019.