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A BILL TO BE ENTITLED
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AN ACT
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relating to certain prohibited practices for certain health benefit |
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plan issuers and certain required and prohibited practices for |
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certain pharmacy benefit managers. |
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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 Subchapters L and M to read as follows: |
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SUBCHAPTER L. AFFILIATED PROVIDERS |
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Sec. 1369.551. DEFINITIONS. In this subchapter: |
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(1) "Affiliated provider" means a pharmacy or durable |
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medical equipment provider that directly, or indirectly through one |
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or more intermediaries, controls, is controlled by, or is under |
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common control with a health benefit plan issuer or pharmacy |
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benefit manager. |
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(2) "Health benefit plan" has the meaning assigned by |
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Section 1369.251. |
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(3) "Pharmacy benefit manager" has the meaning |
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assigned by Section 4151.151. |
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Sec. 1369.552. EXCEPTIONS TO APPLICABILITY OF SUBCHAPTER. |
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Notwithstanding the definition of "health benefit plan" provided by |
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Section 1369.551, this subchapter does not apply to an issuer or |
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provider of health benefits under or a pharmacy benefit manager |
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administering pharmacy benefits under: |
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(1) the state Medicaid program, including the Medicaid |
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managed care program operated under Chapter 533, Government Code; |
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(2) the child health plan program under Chapter 62, |
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Health and Safety Code; |
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(3) the TRICARE military health system; |
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(4) a basic coverage plan under Chapter 1551; |
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(5) a basic plan under Chapter 1575; |
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(6) a primary care coverage plan under Chapter 1579; |
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(7) a plan providing basic coverage under Chapter |
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1601; or |
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(8) a workers' compensation insurance policy or other |
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form of providing medical benefits under Title 5, Labor Code. |
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Sec. 1369.553. TRANSFER OR ACCEPTANCE OF CERTAIN RECORDS |
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PROHIBITED. (a) In this section, "commercial purpose" does not |
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include pharmacy reimbursement, formulary compliance, |
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pharmaceutical care, utilization review by a health care provider, |
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or a public health activity authorized by law. |
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(b) A health benefit plan issuer or pharmacy benefit manager |
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may not transfer to or receive from the issuer's or manager's |
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affiliated provider a record containing patient- or |
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prescriber-identifiable prescription information for a commercial |
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purpose. |
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Sec. 1369.554. PROHIBITION ON CERTAIN COMMUNICATIONS. (a) |
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A health benefit plan issuer or pharmacy benefit manager may not |
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steer or direct a patient to use the issuer's or manager's |
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affiliated provider through any oral or written communication, |
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including: |
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(1) online messaging regarding the provider; or |
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(2) patient- or prospective patient-specific |
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advertising, marketing, or promotion of the provider. |
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(b) This section does not prohibit a health benefit plan |
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issuer or pharmacy benefit manager from including the issuer's or |
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manager's affiliated provider in a patient or prospective patient |
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communication, if the communication: |
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(1) is regarding information about the cost or service |
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provided by pharmacies or durable medical equipment providers in |
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the network of a health benefit plan in which the patient or |
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prospective patient is enrolled; and |
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(2) includes accurate comparable information |
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regarding pharmacies or durable medical equipment providers in the |
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network that are not the issuer's or manager's affiliated |
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providers. |
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Sec. 1369.555. PROHIBITION ON CERTAIN REFERRALS AND |
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SOLICITATIONS. (a) A health benefit plan issuer or pharmacy |
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benefit manager may not require a patient to use the issuer's or |
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manager's affiliated provider in order for the patient to receive |
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the maximum benefit for the service under the patient's health |
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benefit plan. |
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(b) A health benefit plan issuer or pharmacy benefit manager |
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may not offer or implement a health benefit plan that requires or |
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induces a patient to use the issuer's or manager's affiliated |
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provider, including by providing for reduced cost-sharing if the |
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patient uses the affiliated provider. |
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(c) A health benefit plan issuer or pharmacy benefit manager |
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may not solicit a patient or prescriber to transfer a patient |
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prescription to the issuer's or manager's affiliated provider. |
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(d) A health benefit plan issuer or pharmacy benefit manager |
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may not require a pharmacy or durable medical equipment provider |
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that is not the issuer's or manager's affiliated provider to |
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transfer a patient's prescription to the issuer's or manager's |
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affiliated provider without the prior written consent of the |
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patient. |
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SUBCHAPTER M. CLINICIAN-ADMINISTERED DRUGS |
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Sec. 1369.601. DEFINITIONS. In this subchapter: |
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(1) "Affiliated provider" means a pharmacy or durable |
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medical equipment provider that directly, or indirectly through one |
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or more intermediaries, controls, is controlled by, or is under |
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common control with a health benefit plan issuer or pharmacy |
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benefit manager. |
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(2) "Clinician-administered drug" means an outpatient |
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prescription drug other than a vaccine that: |
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(A) cannot reasonably be: |
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(i) self-administered by the patient to |
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whom the drug is prescribed; or |
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(ii) administered by an individual |
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assisting the patient with the self-administration; and |
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(B) is typically administered: |
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(i) by a physician or other health care |
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provider authorized under the laws of this state to administer the |
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drug, including when acting under a physician's delegation and |
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supervision; and |
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(ii) in a physician's office, hospital |
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outpatient infusion center, or other clinical setting. |
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(3) "Health care provider" means an individual who is |
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licensed, certified, or otherwise authorized to provide health care |
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services in this state. |
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(4) "Pharmacy benefit manager" has the meaning |
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assigned by Section 4151.151. |
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(5) "Physician" means an individual licensed to |
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practice medicine in this state. |
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Sec. 1369.602. 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 or surgical expenses incurred as a result of a |
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health condition, accident, or sickness, including an individual, |
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group, blanket, or franchise insurance policy or insurance |
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agreement, a group hospital service contract, or an individual or |
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group evidence of coverage or similar coverage document that is |
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offered 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) 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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(4) a regional or local health care program operating |
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under Section 75.104, Health and Safety Code; and |
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(5) 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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(c) This subchapter does not apply to an issuer or provider |
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of health benefits under or a pharmacy benefit manager |
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administering pharmacy benefits under a workers' compensation |
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insurance policy or other form of providing medical benefits under |
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Title 5, Labor Code. |
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Sec. 1369.603. CERTAIN LIMITATIONS RELATED TO |
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CLINICIAN-ADMINISTERED DRUGS PROHIBITED. (a) A health benefit plan |
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issuer or pharmacy benefit manager may not, for a patient with a |
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cancer or cancer-related diagnosis: |
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(1) require a clinician-administered drug to be |
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dispensed by a pharmacy, including by an affiliated provider; or |
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(2) require that a clinician-administered drug or the |
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administration of a clinician-administered drug be covered as a |
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pharmacy benefit rather than a medical benefit. |
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(b) Nothing in this section may be construed to: |
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(1) authorize a person to administer a drug when |
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otherwise prohibited under the laws of this state or federal law; or |
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(2) modify drug administration requirements under the |
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laws of this state, including any requirements related to |
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delegation and supervision of drug administration. |
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SECTION 2. Sections 1369.555(a) and (b), Insurance Code, as |
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added by this Act, apply only to a health benefit plan delivered, |
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issued for delivery, or renewed on or after the effective date of |
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this Act. |
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SECTION 3. Subchapter M, Chapter 1369, Insurance Code, as |
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added by this Act, applies only to a health benefit plan that is |
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delivered, issued for delivery, or renewed on or after January 1, |
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2022. |
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SECTION 4. This Act takes effect September 1, 2021. |
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* * * * * |