83R3747 PMO-F
By: Eiland H.B. No. 3455
A BILL TO BE ENTITLED
AN ACT
relating to access to pharmaceutical care under certain health
benefit plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 1451, Insurance Code, is amended by
adding Subchapter J to read as follows:
SUBCHAPTER J. ACCESS TO PHARMACEUTICAL CARE
Sec. 1451.451. DEFINITIONS. In this subchapter:
(1) "Drug" has the meaning assigned by Section
551.003, Occupations Code.
(2) "Enrollee" means an individual who is covered
under a health benefit plan, including a covered dependent.
(3) "Pharmaceutical care" has the meaning assigned by
Section 551.003, Occupations Code.
(4) "Pharmacist" has the meaning assigned by Section
551.003, Occupations Code.
(5) "Pharmacy" has the meaning assigned by Section
551.003, Occupations Code.
Sec. 1451.452. APPLICABILITY OF SUBCHAPTER. (a) This
subchapter applies only to a health benefit plan that provides
benefits for drugs or pharmaceutical care 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 fraternal benefit society operating under
Chapter 885;
(4) a stipulated premium company operating under
Chapter 884;
(5) an 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.
(b) This subchapter does not apply to:
(1) a plan that provides coverage:
(A) for wages or payments in lieu of wages for a
period during which an employee is absent from work because of
sickness or injury;
(B) as a supplement to a liability insurance
policy;
(C) for credit insurance;
(D) only for dental or vision care;
(E) only for hospital expenses; or
(F) only for indemnity for hospital confinement;
(2) a Medicare supplemental policy as defined by
Section 1882(g)(1), Social Security Act (42 U.S.C. Section
1395ss(g)(1));
(3) a workers' compensation insurance policy;
(4) medical payment insurance coverage provided under
a motor vehicle insurance policy; or
(5) a long-term care 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 Subsection (a).
Sec. 1451.453. PROHIBITED CONTRACTUAL PROVISIONS. (a) A
health benefit plan may not:
(1) prohibit or limit an enrollee from selecting a
pharmacy or pharmacist of the enrollee's choice to be a provider to
furnish pharmaceutical care covered by the plan;
(2) deny a pharmacy or pharmacist the right to
participate as a provider under the plan if the pharmacy or
pharmacist agrees to provide pharmaceutical care consistent with
the terms of the plan and to accept the administrative, financial,
and professional conditions that apply uniformly to pharmacies and
pharmacists designated as providers under the plan; or
(3) require an enrollee to obtain or request a
specific quantity or dosage supply of pharmaceutical products.
(b) Notwithstanding Subsection (a)(3), a health benefit
plan may allow a physician of an enrollee to prescribe drugs in a
quantity or dosage supply the physician determines appropriate and
that is in compliance with state and federal statutes.
(c) This section does not prohibit a health benefit plan
from:
(1) in an effort to achieve cost savings to the plan
and the enrollee, provided that the limitations or incentives are
applied uniformly to all designated providers of pharmaceutical
care under the plan:
(A) limiting the quantity or dosage supply of
drugs covered under the plan; or
(B) providing financial incentives to
prescribing physicians or enrollees to encourage use of certain
drugs or pharmaceutical care in certain quantities;
(2) implementing or administering a pharmacy benefit
card program that authorizes an enrollee to obtain drugs or
pharmaceutical care through designated providers; or
(3) establishing uniform and reasonable application
and renewal fees for pharmacies or pharmacists that provide
pharmaceutical care as a provider under the plan.
Sec. 1451.454. COVERAGE NOT REQUIRED. This subchapter does
not require a health benefit plan to provide coverage for drugs or
pharmaceutical care.
Sec. 1451.455. DEPARTMENT MONITORING. The commissioner
shall monitor health benefit plans to ensure compliance with this
subchapter.
Sec. 1451.456. RULEMAKING. The commissioner may adopt
rules as necessary to implement this subchapter.
SECTION 2. Article 21.52B, Insurance Code, is repealed.
SECTION 3. This Act applies only to a health benefit plan
that is delivered, issued for delivery, or renewed on or after
January 1, 2014. A health benefit plan delivered, issued for
delivery, or renewed before January 1, 2014, is governed by the law
as it existed immediately before the effective date of this Act, and
that law is continued in effect for that purpose.
SECTION 4. This Act takes effect September 1, 2013.