84R18846 MEW-D
By: Clardy H.B. No. 2505
Substitute the following for H.B. No. 2505:
By: Vo C.S.H.B. No. 2505
A BILL TO BE ENTITLED
AN ACT
relating to health benefit plan coverage for abuse-deterrent opioid
analgesic drugs.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 1369, Insurance Code, is amended by
adding Subchapter H to read as follows:
SUBCHAPTER H. COVERAGE FOR ABUSE-DETERRENT OPIOID ANALGESIC DRUGS
Sec. 1369.351. DEFINITIONS. In this subchapter:
(1) "Abuse-deterrent opioid analgesic drug" means an
opioid analgesic drug that the United States Food and Drug
Administration has approved and for which the United States Food
and Drug Administration has approved abuse-deterrence labeling
that indicates the drug is expected to result in a meaningful
reduction in abuse.
(2) "Opioid analgesic drug" means a drug in the opioid
analgesic drug class that:
(A) is prescribed to treat moderate to severe
pain or other conditions; and
(B) may be:
(i) in an immediate-release or
extended-release form of the drug;
(ii) a single component drug; or
(iii) in combination with another drug.
Sec. 1369.352. APPLICABILITY OF SUBCHAPTER. (a) This
subchapter applies only to a health benefit plan, including a small
employer health benefit plan written under Chapter 1501, that
provides benefits for medical or surgical 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) 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.
(b) Notwithstanding Section 1501.251 or any other law, this
subchapter applies to a small employer health benefit plan subject
to Chapter 1501.
(c) Notwithstanding Sections 1507.004 and 1507.053, or any
other law, this subchapter applies to a consumer choice of benefits
plan issued under Chapter 1507.
Sec. 1369.353. EXCEPTIONS; APPLICATION TO QUALIFIED HEALTH
PLAN. (a) This subchapter does not apply to:
(1) a health benefit plan that provides coverage only:
(A) for a specified disease or for another
limited benefit other than for cancer;
(B) 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) for dental or vision care; or
(G) 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),
as amended;
(3) a workers' compensation insurance policy;
(4) medical payment insurance coverage provided under
a motor vehicle insurance policy; or
(5) 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 1369.102.
(b) This subchapter does not apply to:
(1) a Medicaid managed care program operated under
Chapter 533, Government Code;
(2) a Medicaid program operated under Chapter 32,
Human Resources Code; or
(3) the state child health plan operated under Chapter
62 or 63, Health and Safety Code.
(c) To the extent that providing coverage for
abuse-deterrent opioid analgesic drugs under this section would
otherwise require this state to make a payment under 42 U.S.C.
Section 18031(d)(3)(B)(ii), a qualified health plan, as defined by
45 C.F.R. Section 155.20, is not required to provide a benefit for
the drugs under this section that exceeds the specified essential
health benefits required under 42 U.S.C. Section 18022(b).
Sec. 1369.354. REQUIRED COVERAGE FOR ABUSE-DETERRENT
OPIOID ANALGESIC DRUGS. (a) A health benefit plan must provide
coverage for abuse-deterrent opioid analgesic drugs.
(b) A health benefit plan issuer may not reduce or limit a
payment to a health care professional, or otherwise penalize the
professional, because the professional prescribes or dispenses an
abuse-deterrent opioid analgesic drug.
(c) Nothing in this section may be construed to authorize a
health care professional to dispense a drug.
Sec. 1369.355. PRIOR AUTHORIZATION. (a) A health benefit
plan may require prior authorization for an abuse-deterrent opioid
analgesic drug if the health benefit plan requires prior
authorization for versions of the opioid analgesic drug that do not
have abuse-deterrent properties.
(b) A health benefit plan may not require an enrollee to use
an opioid analgesic drug that does not have abuse-deterrent
properties before prior authorization for an abuse-deterrent
opioid analgesic drug may be given.
SECTION 2. Subchapter H, Chapter 1369, Insurance Code, as
added by this Act, applies only to a health benefit plan that is
delivered, issued for delivery, or renewed on or after January 1,
2016. A health benefit plan that is delivered, issued for delivery,
or renewed before January 1, 2016, is covered by the law in effect
at the time the plan was delivered, issued for delivery, or renewed,
and that law is continued in effect for that purpose.
SECTION 3. This Act takes effect September 1, 2015.