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A BILL TO BE ENTITLED
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AN ACT
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relating to a limit on cost-sharing requirements imposed by a |
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health benefit plan for certain prescription insulin. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Chapter 1358, Insurance Code, is amended by |
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adding Subchapter C to read as follows: |
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SUBCHAPTER C. COST-SHARING LIMIT |
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Sec. 1358.101. DEFINITIONS. In this subchapter: |
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(1) "Insulin" means a prescription drug that contains |
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insulin and is used to treat diabetes. |
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(2) "Pharmacy benefit manager" means a person, other |
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than a pharmacy or pharmacist, who acts as an administrator in |
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connection with pharmacy benefits. |
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Sec. 1358.102. 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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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; and |
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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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(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. 1358.103. LIMIT ON COST-SHARING REQUIREMENT. A |
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health benefit plan may not impose a cost-sharing provision for |
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insulin if the total amount the enrollee is required to pay exceeds |
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$25 for a 30-day supply. |
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Sec. 1358.104. LIMITATION ON PHARMACY CONTRACTS. A |
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contract between a health benefit plan issuer or pharmacy benefit |
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manager and a pharmacy may not contain a provision: |
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(1) authorizing the issuer's pharmacy benefit manager |
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or the pharmacy to charge an amount for insulin greater than the |
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amount described by Section 1358.103; |
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(2) requiring the pharmacy to collect an amount for |
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insulin greater than the amount described by Section 1358.103; or |
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(3) requiring an enrollee to make a cost-sharing |
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payment for covered insulin in an amount that exceeds the amount |
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described by Section 1358.103. |
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SECTION 2. (a) Section 1358.103, Insurance Code, as added |
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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. A health benefit plan delivered, issued for delivery, or |
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renewed before January 1, 2022, is governed by the law as it existed |
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immediately before the effective date of this Act, and that law is |
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continued in effect for that purpose. |
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(b) Section 1358.104, Insurance Code, as added by this Act, |
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applies only to a contract entered into or renewed on or after the |
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effective date of this Act. |
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SECTION 3. This Act takes effect September 1, 2021. |