| |
| |
|
|
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. |