By: Smithee, Hardcastle, Eiland, Nash H.B. No. 1405
A BILL TO BE ENTITLED
AN ACT
relating to provision by a health benefit plan of prescription drug
coverage specified by formulary.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 1369.051(2), Insurance Code, is amended
to read as follows:
(2) "Enrollee" means an individual who is covered
under a [group] health benefit plan, including a covered dependent.
SECTION 2. Section 1369.052, Insurance Code, is amended to
read as follows:
Sec. 1369.052. APPLICABILITY OF SUBCHAPTER. This
subchapter applies only to a [group] 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, [a] group, blanket, or franchise insurance policy or
insurance agreement, a group hospital service contract, or a small
or large employer group contract or similar coverage document that
is offered by:
(1) an insurance company;
(2) a group hospital service corporation operating
under Chapter 842;
(3) a fraternal benefit society operating under
Chapter 885;
(4) a stipulated premium company operating under
Chapter 884;
(5) a reciprocal exchange operating under Chapter 942;
(6) a health maintenance organization operating under
Chapter 843;
(7) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846; or
(8) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844.
SECTION 3. Section 1369.053, Insurance Code, is amended to
read as follows:
Sec. 1369.053. EXCEPTION. This subchapter does not apply
to:
(1) a health benefit plan that provides coverage:
(A) only for a specified disease or for another
single benefit;
(B) only for accidental death or dismemberment;
(C) for wages or payments in lieu of wages for a
period during which an employee is absent from work because of
sickness or injury;
(D) as a supplement to a liability insurance
policy;
(E) for credit insurance;
(F) only for dental or vision care;
(G) only for hospital expenses; or
(H) only for indemnity for hospital confinement;
(2) [a small employer health benefit plan written
under Chapter 1501;
[(3)] a Medicare supplemental policy as defined by
Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss),
as amended;
(3) [(4)] a workers' compensation insurance policy;
(4) [(5)] medical payment insurance coverage provided
under a motor vehicle insurance policy; [or]
(5) [(6)] a long-term care insurance policy, including
a nursing home fixed indemnity policy, unless the commissioner
determines that the policy provides benefit coverage so
comprehensive that the policy is a health benefit plan as described
by Section 1369.052;
(6) the child health plan program under Chapter 62,
Health and Safety Code, or the health benefits plan for children
under Chapter 63, Health and Safety Code; or
(7) a Medicaid managed care program operated under
Chapter 533, Government Code, or a Medicaid program operated under
Chapter 32, Human Resources Code.
SECTION 4. Section 1369.054, Insurance Code, is amended to
read as follows:
Sec. 1369.054. NOTICE AND DISCLOSURE OF CERTAIN INFORMATION
REQUIRED. An issuer of a [group] health benefit plan that covers
prescription drugs and uses one or more drug formularies to specify
the prescription drugs covered under the plan shall:
(1) provide in plain language in the coverage
documentation provided to each enrollee:
(A) notice that the plan uses one or more drug
formularies;
(B) an explanation of what a drug formulary is;
(C) a statement regarding the method the issuer
uses to determine the prescription drugs to be included in or
excluded from a drug formulary;
(D) a statement of how often the issuer reviews
the contents of each drug formulary; and
(E) notice that an enrollee may contact the
issuer to determine whether a specific drug is included in a
particular drug formulary;
(2) disclose to an individual on request, not later
than the third business day after the date of the request, whether a
specific drug is included in a particular drug formulary; and
(3) notify an enrollee and any other individual who
requests information under this section that the inclusion of a
drug in a drug formulary does not guarantee that an enrollee's
health care provider will prescribe that drug for a particular
medical condition or mental illness.
SECTION 5. Section 1369.055, Insurance Code, is amended to
read as follows:
Sec. 1369.055. CONTINUATION OF COVERAGE REQUIRED; OTHER
DRUGS NOT PRECLUDED. (a) An issuer of a [group] health benefit plan
that covers prescription drugs shall offer to each enrollee at the
contracted benefit level and until the enrollee's plan renewal date
any prescription drug that was approved or covered under the plan
for a medical condition or mental illness, regardless of whether
the drug has been removed from the health benefit plan's drug
formulary before the plan renewal date.
(b) This section does not prohibit a physician or other
health professional who is authorized to prescribe a drug from
prescribing a drug that is an alternative to a drug for which
continuation of coverage is required under Subsection (a) if the
alternative drug is:
(1) covered under the [group] health benefit plan; and
(2) medically appropriate for the enrollee.
SECTION 6. Section 1369.056(a), Insurance Code, is amended
to read as follows:
(a) The refusal of a [group] health benefit plan issuer to
provide benefits to an enrollee for a prescription drug is an
adverse determination for purposes of Section 4201.002 if:
(1) the drug is not included in a drug formulary used
by the [group] health benefit plan; and
(2) the enrollee's physician has determined that the
drug is medically necessary.
SECTION 7. The change in law made by this Act applies only
to a health benefit plan delivered, issued for delivery, or renewed
on or after January 1, 2012. A health benefit plan delivered,
issued for delivery, or renewed before January 1, 2012, is governed
by the law in effect immediately before the effective date of this
Act, and that law is continued in effect for that purpose.
SECTION 8. This Act takes effect September 1, 2011.