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A BILL TO BE ENTITLED
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AN ACT
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relating to the effect of certain reductions in a health benefit |
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plan enrollee's out-of-pocket expenses for prescription drugs that |
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are essential health benefits on the enrollee's cost-sharing |
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requirements. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 1369.0542, Insurance Code, is amended by |
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amending Subsection (a) and adding Subsection (c) to read as |
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follows: |
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(a) Subsection (b) [This section] applies only to a |
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reduction in out-of-pocket expenses made by or on behalf of an |
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enrollee for a prescription drug covered by the enrollee's health |
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benefit plan for which: |
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(1) a generic equivalent does not exist; |
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(2) a generic equivalent does exist but the enrollee |
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has obtained access to the prescription drug under the enrollee's |
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health benefit plan using: |
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(A) a prior authorization process; |
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(B) a step therapy protocol; or |
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(C) the health benefit plan issuer's exceptions |
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and appeals process; |
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(3) an interchangeable biological product does not |
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exist; or |
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(4) an interchangeable biological product does exist |
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but the enrollee has obtained access to the prescription drug under |
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the enrollee's health benefit plan using: |
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(A) a prior authorization process; |
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(B) a step therapy protocol; or |
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(C) the health benefit plan issuer's exceptions |
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and appeals process. |
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(c) An issuer of a health benefit plan that covers |
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prescription drugs, pharmacy benefit manager, or subcontractor |
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shall apply any reduction in out-of-pocket expenses made on behalf |
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of an enrollee for a prescription drug that is included within a |
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category of essential health benefits under 42 U.S.C. Section |
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18022(b)(1), regardless of whether the health benefit plan issuer, |
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pharmacy benefit manager, or subcontractor classifies the drug as |
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an essential health benefit, to the enrollee's deductible, |
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copayment, cost-sharing responsibility, or out-of-pocket maximum |
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applicable to health benefits under the enrollee's plan. In this |
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subsection, "subcontractor" means a person or entity, other than an |
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employee of a health benefit plan issuer or pharmacy benefit |
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manager, to whom the health benefit plan issuer or pharmacy benefit |
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manager delegates the performance of a function, activity, or |
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service. |
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SECTION 2. Section 1369.0542, Insurance Code, as amended by |
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this Act, applies only to a health benefit plan that is delivered, |
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issued for delivery, or renewed on or after January 1, 2026. A |
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health benefit plan delivered, issued for delivery, or renewed |
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before January 1, 2026, 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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SECTION 3. This Act takes effect September 1, 2025. |