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A BILL TO BE ENTITLED
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AN ACT
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relating to specialty prescription drug coverage. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 1369.001, Insurance Code, is amended by |
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adding Subsections (05) through (09) to read as follows: |
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(05) "Pharmacy benefit manager" has the meaning |
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assigned by Section 4151.151. |
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(06) "Pharmacy benefit contract" means an agreement |
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between an entity licensed under the insurance laws of this state |
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and an enrollee for the coverage of prescription drugs; |
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(07) "Prescription drug" has the meaning assigned by |
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Section 551.003, Occupations Code, except that the term |
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"prescription drug" does not include a device or an animal health |
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product. |
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(08) "Specialty drug" means a prescription drug that |
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is |
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(A) prescribed to a person with a chronic, |
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complex, rare, or life threatening medical condition; |
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(B) available in injectable, infusion, |
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inhalable, implantable, or oral form; and |
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(C) not usually self-administered by a patient. |
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(09) "Hospital outpatient infusion center" means a |
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health care facility where a patient receives infusion therapy on |
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an outpatient basis. |
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SECTION 2. Section 1369, Insurance Code, is amended by |
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adding Section 1369.0042 to read as follows: |
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Sec. 1369.0042. SPECIALTY DRUGS. (a) A health benefit plan |
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issuer or pharmacy benefit manager shall: |
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(1) permit an enrollee to obtain a specialty drug from |
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a physician's office or hospital outpatient infusion center that |
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provides and administers a specialty drug; |
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(2) permit a person covered under a pharmacy benefit |
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contract that provides coverage for prescription drugs to obtain a |
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specialty drug from a physician's office, or hospital outpatient |
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infusion center, that provides and administers the specialty drug; |
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(3) not limit coverage or benefits of an enrollee of a |
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health benefit plan or person covered under a pharmacy benefit |
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contract; |
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(4) not require an enrollee of a health benefit plan |
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that provides coverage for specialty drugs to pay an additional |
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fee, higher copay, higher coinsurance, second copay, second |
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coinsurance, or any other penalty, if the person obtains a |
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specialty drug from a physician's office, or a hospital outpatient |
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infusion center, that provides and administers a specialty drug; |
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(5) not require a person covered under a pharmacy |
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benefit contract that provides coverage for specialty drugs to pay |
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an additional fee, higher copay, higher coinsurance, second copay, |
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second coinsurance, or any other penalty if the person obtains a |
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specialty drug from a physician's office, or a hospital outpatient |
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infusion center, that provides and administers a specialty drug; |
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(6) not require a hospital, physician's office, or |
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hospital outpatient infusion center to obtain a specialty drug from |
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a participating pharmacy in the health benefit plan issuer's |
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network; and |
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(7) not, condition, deny, restrict, or otherwise |
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reduce payment to a hospital, pharmacy, physician's office, or |
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hospital outpatient infusion center for a specialty drug because a |
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hospital, physician's office, or hospital outpatient infusion |
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center obtains a specialty drug from a pharmacy that does not |
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participate in the health benefit plan issuer's network. |
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SECTION 3. This Act takes effect September 1, 2021. |