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A BILL TO BE ENTITLED
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AN ACT
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relating to prior authorization for prescription drug benefits |
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related to the treatment of chronic and autoimmune diseases. |
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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 L to read as follows: |
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SUBCHAPTER L. COVERAGE OF PRESCRIPTION DRUGS FOR CHRONIC AND |
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AUTOIMMUNE DISEASES |
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Sec. 1369.551. DEFINITION. In this subchapter, |
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"prescription drug" has the meaning assigned by Section 551.003, |
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Occupations Code. |
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Sec. 1369.552. 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, surgical, or prescription drug expenses |
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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; |
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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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(13) county employee group health benefits provided |
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under Chapter 157, Local Government Code; and |
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(14) health and accident coverage provided by a risk |
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pool created under Chapter 172, Local Government 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. 1369.553. EXCEPTIONS. (a) This subchapter does not |
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apply to: |
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(1) a plan that provides coverage: |
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(A) for wages or payments in lieu of wages for a |
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period during which an employee is absent from work because of |
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sickness or injury; |
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(B) as a supplement to a liability insurance |
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policy; |
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(C) for credit insurance; |
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(D) only for dental or vision care; |
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(E) only for hospital expenses; or |
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(F) only for indemnity for hospital confinement; |
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(2) a Medicare supplemental policy as defined by |
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Section 1882(g)(1), Social Security Act (42 U.S.C. Section |
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1395ss(g)(1)); |
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(3) a workers' compensation insurance policy; |
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(4) medical payment insurance coverage provided under |
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a motor vehicle insurance policy; or |
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(5) a long-term care policy, including a nursing home |
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fixed indemnity policy, unless the commissioner determines that the |
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policy provides benefit coverage so comprehensive that the policy |
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is a health benefit plan as described by Section 1369.552. |
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(b) This subchapter does not apply to an individual health |
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benefit plan issued on or before March 23, 2010, that has not had |
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any significant changes since that date that reduce benefits or |
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increase costs to the individual. |
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Sec. 1369.554. PROHIBITION ON PRIOR AUTHORIZATION. A |
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health benefit plan issuer that provides prescription drug benefits |
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may not require prior authorization of the prescription drug |
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benefit for a prescription drug prescribed to treat a chronic or |
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autoimmune disease. |
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SECTION 2. The change in law made by this Act applies only |
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to a health benefit plan that is delivered, issued for delivery, or |
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renewed on or after January 1, 2022. |
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SECTION 3. If before implementing any provision of this Act |
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a state agency determines that a waiver or authorization from a |
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federal agency is necessary for implementation of that provision, |
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the agency affected by the provision shall request the waiver or |
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authorization and may delay implementing that provision until the |
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waiver or authorization is granted. |
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SECTION 4. This Act takes effect September 1, 2021. |