By: Harris, et al. H.B. No. 1919
        (Senate Sponsor - Schwertner, et al.)
         (In the Senate - Received from the House May 3, 2021;
  May 13, 2021, read first time and referred to Committee on Health &
  Human Services; May 21, 2021, reported adversely, with favorable
  Committee Substitute by the following vote:  Yeas 8, Nays 0;
  May 21, 2021, sent to printer.)
Click here to see the committee vote
 
  COMMITTEE SUBSTITUTE FOR H.B. No. 1919 By:  Perry
 
 
A BILL TO BE ENTITLED
 
AN ACT
 
  relating to certain prohibited practices for certain health benefit
  plan issuers and certain required and prohibited practices for
  certain pharmacy benefit managers.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Chapter 1369, Insurance Code, is amended by
  adding Subchapters L and M to read as follows:
  SUBCHAPTER L. AFFILIATED PROVIDERS
         Sec. 1369.551.  DEFINITIONS. In this subchapter:
               (1)  "Affiliated provider" means a pharmacy or durable
  medical equipment provider that directly, or indirectly through one
  or more intermediaries, controls, is controlled by, or is under
  common control with a health benefit plan issuer or pharmacy
  benefit manager.
               (2)  "Health benefit plan" has the meaning assigned by
  Section 1369.251.
               (3)  "Pharmacy benefit manager" has the meaning
  assigned by Section 4151.151.
         Sec. 1369.552.  EXCEPTIONS TO APPLICABILITY OF SUBCHAPTER.
  Notwithstanding the definition of "health benefit plan" provided by
  Section 1369.551, this subchapter does not apply to an issuer or
  provider of health benefits under or a pharmacy benefit manager
  administering pharmacy benefits under:
               (1)  the state Medicaid program, including the Medicaid
  managed care program operated under Chapter 533, Government Code;
               (2)  the child health plan program under Chapter 62,
  Health and Safety Code;
               (3)  the TRICARE military health system;
               (4)  a basic coverage plan under Chapter 1551;
               (5)  a basic plan under Chapter 1575;
               (6)  a primary care coverage plan under Chapter 1579;
               (7)  a plan providing basic coverage under Chapter
  1601; or
               (8)  a workers' compensation insurance policy or other
  form of providing medical benefits under Title 5, Labor Code.
         Sec. 1369.553.  TRANSFER OR ACCEPTANCE OF CERTAIN RECORDS
  PROHIBITED. (a) In this section, "commercial purpose" does not
  include pharmacy reimbursement, formulary compliance,
  pharmaceutical care, utilization review by a health care provider,
  or a public health activity authorized by law.
         (b)  A health benefit plan issuer or pharmacy benefit manager
  may not transfer to or receive from the issuer's or manager's
  affiliated provider a record containing patient- or
  prescriber-identifiable prescription information for a commercial
  purpose.
         Sec. 1369.554.  PROHIBITION ON CERTAIN COMMUNICATIONS. (a)
  A health benefit plan issuer or pharmacy benefit manager may not
  steer or direct a patient to use the issuer's or manager's
  affiliated provider through any oral or written communication,
  including:
               (1)  online messaging regarding the provider; or
               (2)  patient- or prospective patient-specific
  advertising, marketing, or promotion of the provider.
         (b)  This section does not prohibit a health benefit plan
  issuer or pharmacy benefit manager from including the issuer's or
  manager's affiliated provider in a patient or prospective patient
  communication, if the communication:
               (1)  is regarding information about the cost or service
  provided by pharmacies or durable medical equipment providers in
  the network of a health benefit plan in which the patient or
  prospective patient is enrolled; and
               (2)  includes accurate comparable information
  regarding pharmacies or durable medical equipment providers in the
  network that are not the issuer's or manager's affiliated
  providers.
         Sec. 1369.555.  PROHIBITION ON CERTAIN REFERRALS AND
  SOLICITATIONS. (a) A health benefit plan issuer or pharmacy
  benefit manager may not require a patient to use the issuer's or
  manager's affiliated provider in order for the patient to receive
  the maximum benefit for the service under the patient's health
  benefit plan.
         (b)  A health benefit plan issuer or pharmacy benefit manager
  may not offer or implement a health benefit plan that requires or
  induces a patient to use the issuer's or manager's affiliated
  provider, including by providing for reduced cost-sharing if the
  patient uses the affiliated provider.
         (c)  A health benefit plan issuer or pharmacy benefit manager
  may not solicit a patient or prescriber to transfer a patient
  prescription to the issuer's or manager's affiliated provider.
         (d)  A health benefit plan issuer or pharmacy benefit manager
  may not require a pharmacy or durable medical equipment provider
  that is not the issuer's or manager's affiliated provider to
  transfer a patient's prescription to the issuer's or manager's
  affiliated provider without the prior written consent of the
  patient.
  SUBCHAPTER M. CLINICIAN-ADMINISTERED DRUGS
         Sec. 1369.601.  DEFINITIONS. In this subchapter:
               (1)  "Affiliated provider" means a pharmacy or durable
  medical equipment provider that directly, or indirectly through one
  or more intermediaries, controls, is controlled by, or is under
  common control with a health benefit plan issuer or pharmacy
  benefit manager.
               (2)  "Clinician-administered drug" means an outpatient
  prescription drug other than a vaccine that:
                     (A)  cannot reasonably be:
                           (i)  self-administered by the patient to
  whom the drug is prescribed; or
                           (ii)  administered by an individual
  assisting the patient with the self-administration; and
                     (B)  is typically administered:
                           (i)  by a physician or other health care
  provider authorized under the laws of this state to administer the
  drug, including when acting under a physician's delegation and
  supervision; and
                           (ii)  in a physician's office, hospital
  outpatient infusion center, or other clinical setting.
               (3)  "Health care provider" means an individual who is
  licensed, certified, or otherwise authorized to provide health care
  services in this state.
               (4)  "Pharmacy benefit manager" has the meaning
  assigned by Section 4151.151.
               (5)  "Physician" means an individual licensed to
  practice medicine in this state.
         Sec. 1369.602.  APPLICABILITY OF SUBCHAPTER. (a) This
  subchapter applies only to a health benefit plan that provides
  benefits for medical or surgical expenses incurred as a result of a
  health condition, accident, or sickness, including an individual,
  group, blanket, or franchise insurance policy or insurance
  agreement, a group hospital service contract, or an individual or
  group evidence of coverage or similar coverage document that is
  offered by:
               (1)  an insurance company;
               (2)  a group hospital service corporation operating
  under Chapter 842;
               (3)  a health maintenance organization operating under
  Chapter 843;
               (4)  an approved nonprofit health corporation that
  holds a certificate of authority under Chapter 844;
               (5)  a multiple employer welfare arrangement that holds
  a certificate of authority under Chapter 846;
               (6)  a stipulated premium company operating under
  Chapter 884;
               (7)  a fraternal benefit society operating under
  Chapter 885;
               (8)  a Lloyd's plan operating under Chapter 941; or
               (9)  an exchange operating under Chapter 942.
         (b)  Notwithstanding any other law, this subchapter applies
  to:
               (1)  a small employer health benefit plan subject to
  Chapter 1501, including coverage provided through a health group
  cooperative under Subchapter B of that chapter;
               (2)  a standard health benefit plan issued under
  Chapter 1507;
               (3)  health benefits provided by or through a church
  benefits board under Subchapter I, Chapter 22, Business
  Organizations Code;
               (4)  a regional or local health care program operating
  under Section 75.104, Health and Safety Code; and
               (5)  a self-funded health benefit plan sponsored by a
  professional employer organization under Chapter 91, Labor Code.
         (c)  This subchapter does not apply to an issuer or provider
  of health benefits under or a pharmacy benefit manager
  administering pharmacy benefits under a workers' compensation
  insurance policy or other form of providing medical benefits under
  Title 5, Labor Code.
         Sec. 1369.603.  CERTAIN LIMITATIONS RELATED TO
  CLINICIAN-ADMINISTERED DRUGS PROHIBITED. (a) A health benefit plan
  issuer or pharmacy benefit manager may not, for a patient with a
  cancer or cancer-related diagnosis:
               (1)  require a clinician-administered drug to be
  dispensed by a pharmacy, including by an affiliated provider; or
               (2)  require that a clinician-administered drug or the
  administration of a clinician-administered drug be covered as a
  pharmacy benefit rather than a medical benefit.
         (b)  Nothing in this section may be construed to:
               (1)  authorize a person to administer a drug when
  otherwise prohibited under the laws of this state or federal law; or
               (2)  modify drug administration requirements under the
  laws of this state, including any requirements related to
  delegation and supervision of drug administration.
         SECTION 2.  Sections 1369.555(a) and (b), Insurance Code, as
  added by this Act, apply only to a health benefit plan delivered,
  issued for delivery, or renewed on or after the effective date of
  this Act.
         SECTION 3.  Subchapter M, Chapter 1369, Insurance Code, as
  added by this Act, applies only to a health benefit plan that is
  delivered, issued for delivery, or renewed on or after January 1,
  2022.
         SECTION 4.  This Act takes effect September 1, 2021.
 
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