By: Lucio III H.B. No. 1586

A BILL TO BE ENTITLED

AN ACT

relating to specialty prescription drug coverage.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Section 1369.001, Insurance Code, is amended by adding Subsections (05) through (09) to read as follows:

(05) "Pharmacy benefit manager" has the meaning assigned by Section 4151.151.

(06) "Pharmacy benefit contract" means an agreement between an entity licensed under the insurance laws of this state and an enrollee for the coverage of prescription drugs;

(07) "Prescription drug" has the meaning assigned by Section 551.003, Occupations Code, except that the term "prescription drug" does not include a device or an animal health product.

(08) "Specialty drug" means a prescription drug that is

(A) prescribed to a person with a chronic, complex, rare, or life threatening medical condition;

(B) available in injectable, infusion, inhalable, implantable, or oral form; and

(C) not usually self-administered by a patient.

(09) "Hospital outpatient infusion center" means a health care facility where a patient receives infusion therapy on an outpatient basis.

SECTION 2. Section 1369, Insurance Code, is amended by adding Section 1369.0042 to read as follows:

Sec. 1369.0042. SPECIALTY DRUGS. (a) A health benefit plan issuer or pharmacy benefit manager shall:

(1) permit an enrollee to obtain a specialty drug from a physician's office or hospital outpatient infusion center that provides and administers a specialty drug;

(2) permit a person covered under a pharmacy benefit contract that provides coverage for prescription drugs to obtain a specialty drug from a physician's office, or hospital outpatient infusion center, that provides and administers the specialty drug;

(3) not limit coverage or benefits of an enrollee of a health benefit plan or person covered under a pharmacy benefit contract;

(4) not require an enrollee of a health benefit plan that provides coverage for specialty drugs to pay an additional fee, higher copay, higher coinsurance, second copay, second coinsurance, or any other penalty, if the person obtains a specialty drug from a physician's office, or a hospital outpatient infusion center, that provides and administers a specialty drug;

(5) not require a person covered under a pharmacy benefit contract that provides coverage for specialty drugs to pay an additional fee, higher copay, higher coinsurance, second copay, second coinsurance, or any other penalty if the person obtains a specialty drug from a physician's office, or a hospital outpatient infusion center, that provides and administers a specialty drug;

(6) not require a hospital, physician's office, or hospital outpatient infusion center to obtain a specialty drug from a participating pharmacy in the health benefit plan issuer's network; and

(7) not, condition, deny, restrict, or otherwise reduce payment to a hospital, pharmacy, physician's office, or hospital outpatient infusion center for a specialty drug because a hospital, physician's office, or hospital outpatient infusion center obtains a specialty drug from a pharmacy that does not participate in the health benefit plan issuer's network.

SECTION 3. This Act takes effect September 1, 2021.