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A BILL TO BE ENTITLED
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AN ACT
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relating to the disclosure of certain prescription drug information |
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by a health benefit plan. |
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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 Subchapter B-2 to read as follows: |
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SUBCHAPTER B-2. DISCLOSURE OF CERTAIN PRESCRIPTION DRUG |
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INFORMATION SPECIFIED BY DRUG FORMULARY |
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Sec. 1369.091. DEFINITIONS. In this subchapter: |
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(1) "Cost-sharing information" means the actual |
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out-of-pocket amount an enrollee is required to pay a dispensing |
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pharmacy or prescribing provider for a prescription drug under the |
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enrollee's health benefit plan. |
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(2) "Drug formulary," "enrollee," and "prescription |
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drug" have the meanings assigned by Section 1369.051. |
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(3) "Standard API" means an application interface that |
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meets the requirements of an applicable American National Standards |
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Institute (ANSI) accredited standard to conform to standards |
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adopted under 45 C.F.R. Section 170.215. |
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Sec. 1369.092. 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) 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) nonprofit agricultural organization health |
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benefits offered by a nonprofit agricultural organization under |
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Chapter 1682; |
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(8) alternative health benefit coverage offered by a |
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subsidiary of the Texas Mutual Insurance Company under Subchapter |
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M, Chapter 2054; |
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(9) 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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(10) 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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Sec. 1369.093. EXCEPTIONS TO APPLICABILITY OF SUBCHAPTER. |
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This subchapter does not apply to an issuer or provider of health |
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benefits under or a pharmacy benefit manager administering pharmacy |
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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; or |
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(4) 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. 1369.094. DISCLOSURE OF PRESCRIPTION DRUG |
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INFORMATION. (a) This section applies only with respect to a |
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prescription drug covered under a health benefit plan's pharmacy |
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benefit. |
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(b) A health benefit plan issuer that covers prescription |
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drugs shall provide information regarding a covered prescription |
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drug to an enrollee or the enrollee's prescribing provider on |
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request. The information provided must include the issuer's drug |
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formulary and, for the prescription drug and any formulary |
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alternative: |
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(1) the enrollee's eligibility; |
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(2) cost-sharing information, including any |
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deductible, copayment, or coinsurance, which must: |
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(A) be consistent with cost-sharing requirements |
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under the enrollee's plan; |
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(B) be accurate at the time the cost-sharing |
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information is provided; and |
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(C) include any variance in cost-sharing based on |
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the patient's preferred dispensing retail or mail-order pharmacy or |
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the prescribing provider; and |
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(3) applicable utilization management requirements. |
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(c) In providing the information required under Subsection |
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(b), a health benefit plan issuer shall: |
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(1) respond in real time to a request made through a |
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standard API; |
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(2) allow the use of an integrated technology or |
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service as necessary to provide the required information; |
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(3) ensure that the information provided is current no |
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later than one business day after the date a change is made; and |
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(4) provide the information if the request is made |
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using the drug's unique billing code and National Drug Code. |
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(d) A health benefit plan issuer may not: |
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(1) deny or delay a response to a request for |
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information under Subsection (b) for the purpose of blocking the |
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release of the information; |
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(2) restrict a prescribing provider from |
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communicating to the enrollee the information provided under |
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Subsection (b), information about the cash price of the drug, or any |
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additional information on any lower cost or clinically appropriate |
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alternative drug, whether or not the drug is covered under the |
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enrollee's plan; |
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(3) except as required by law, interfere with, |
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prevent, or materially discourage access to or the exchange or use |
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of the information provided under Subsection (b), including by: |
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(A) charging a fee to access the information; |
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(B) not responding to a request within the time |
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required by this section; or |
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(C) instituting a consent requirement for an |
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enrollee to access the information; or |
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(4) penalize, including by taking any action intended |
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to punish or discourage future similar behavior by the prescribing |
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provider, a prescribing provider for: |
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(A) disclosing the information provided under |
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Subsection (b); or |
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(B) prescribing, administering, or ordering a |
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lower cost or clinically appropriate alternative drug. |
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(e) A health benefit plan issuer with fewer than 10,000 |
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enrollees may: |
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(1) register with the department to receive an |
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additional 12 months after the effective date of this subchapter to |
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comply with the requirements of this subchapter; and |
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(2) after the additional 12 months provided for in |
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Subdivision (1), request from the department a temporary exception |
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from one or more requirements of this section by submitting a report |
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to the department that demonstrates that compliance would impose an |
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unreasonable cost relative to the public value that would be gained |
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from full compliance. |
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SECTION 2. The changes in law made by this Act apply only to |
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a health benefit plan delivered, issued for delivery, or renewed on |
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or after January 1, 2025. |
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SECTION 3. This Act takes effect September 1, 2023. |