Texas 2015 - 84th Regular

Texas House Bill HB3025 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New	Differences
1	1	84R22517 PMO-F
2	2	By: Farney, et al. H.B. No. 3025
3	3	Substitute the following for H.B. No. 3025:
4	4	By: Meyer C.S.H.B. No. 3025
5	5
6	6
7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to health benefit coverage for prescription drug
10	10	synchronization.
11	11	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12	12	SECTION 1. Chapter 1369, Insurance Code, is amended by
13	13	adding Subchapter H to read as follows:
14	14	SUBCHAPTER H. COVERAGE RELATED TO PRESCRIPTION DRUG
15	15	SYNCHRONIZATION
16	16	Sec. 1369.351. DEFINITIONS. In this subchapter:
17	17	(1) "Cost-sharing amount" includes an amount charged
18	18	for a deductible, coinsurance, or copayment.
19	19	(2) "Health care provider" means a person who provides
20	20	health care services under a license, certificate, registration, or
21	21	other similar evidence of regulation issued by this or another
22	22	state of the United States.
23	23	(3) "Physician" means an individual licensed to
24	24	practice medicine in this or another state of the United States.
25	25	Sec. 1369.352. APPLICABILITY OF SUBCHAPTER. (a) This
26	26	subchapter applies only to a health benefit plan that provides
27	27	benefits for medical or surgical expenses incurred as a result of a
28	28	health condition, accident, or sickness, including an individual,
29	29	group, blanket, or franchise insurance policy or insurance
30	30	agreement, a group hospital service contract, or an individual or
31	31	group evidence of coverage or similar coverage document that is
32	32	offered by:
33	33	(1) an insurance company;
34	34	(2) a group hospital service corporation operating
35	35	under Chapter 842;
36	36	(3) a health maintenance organization operating under
37	37	Chapter 843;
38	38	(4) an approved nonprofit health corporation that
39	39	holds a certificate of authority under Chapter 844;
40	40	(5) a multiple employer welfare arrangement that holds
41	41	a certificate of authority under Chapter 846;
42	42	(6) a stipulated premium company operating under
43	43	Chapter 884;
44	44	(7) a fraternal benefit society operating under
45	45	Chapter 885; or
46	46	(8) an exchange operating under Chapter 942.
47	47	(b) This subchapter applies to group health coverage made
48	48	available by a school district in accordance with Section 22.004,
49	49	Education Code.
50	50	(c) Notwithstanding any provision in Chapter 1551, 1575,
51	51	1579, or 1601 or any other law, this subchapter applies to health
52	52	benefit plan coverage provided under:
53	53	(1) Chapter 1551;
54	54	(2) Chapter 1575;
55	55	(3) Chapter 1579; and
56	56	(4) Chapter 1601.
57	57	(d) Notwithstanding Section 1501.251 or any other law, this
58	58	subchapter applies to coverage under a small employer health
59	59	benefit plan subject to Chapter 1501.
60	60	(e) This subchapter applies to a consumer choice of benefits
61	61	plan issued under Chapter 1507.
62	62	(f) To the extent allowed by federal law, the child health
63	63	plan program operated under Chapter 62, Health and Safety Code, the
64	64	health benefits plan for children operated under Chapter 63, Health
65	65	and Safety Code, the state Medicaid program, and a managed care
66	66	organization that contracts with the Health and Human Services
67	67	Commission to provide health care services to Medicaid recipients
68	68	through a managed care plan shall provide the coverage required
69	69	under this subchapter to a recipient.
70	70	Sec. 1369.353. PRORATION OF COST-SHARING AMOUNT REQUIRED.
71	71	(a) A health benefit plan that provides benefits for prescription
72	72	drugs shall prorate any cost-sharing amount charged for a
73	73	prescription drug dispensed in a quantity that is less than a 30
74	74	days' supply if:
75	75	(1) the pharmacy or the covered person's prescribing
76	76	physician or health care provider notifies the health benefit plan
77	77	that:
78	78	(A) the quantity dispensed is to synchronize the
79	79	dates that the pharmacy dispenses the covered person's prescription
80	80	drugs; and
81	81	(B) the synchronization of the dates is in the
82	82	best interest of the covered person; and
83	83	(2) the covered person agrees to the synchronization.
84	84	(b) The proration described by Subsection (a) must be based
85	85	on the number of days' supply of the drug actually dispensed.
86	86	Sec. 1369.354. PRORATION OF DISPENSING FEE PROHIBITED. A
87	87	health benefit plan that prorates a cost-sharing amount as required
88	88	by Section 1369.353 may not prorate the fee paid to the pharmacy for
89	89	dispensing the drug for which the cost-sharing amount was prorated.
90	90	Sec. 1369.355. IMPLEMENTATION OF CERTAIN MEDICATION
91	91	SYNCHRONIZATION PLANS. (a) For the purposes of this section:
92	92	(1) "Chronic illness" means an illness or physical
93	93	condition that may be:
94	94	(A) reasonably expected to continue for an
95	95	uninterrupted period of at least three months; and
96	96	(B) controlled but not cured by medical
97	97	treatment.
98	98	(2) "Medication synchronization plan" means a plan
99	99	established for the purpose of synchronizing the filling or
100	100	refilling of multiple prescriptions.
101	101	(b) A health benefit plan shall establish a process through
102	102	which the following parties may jointly approve a medication
103	103	synchronization plan for medication to treat a covered person's
104	104	chronic illness:
105	105	(1) the health benefit plan;
106	106	(2) the covered person;
107	107	(3) the prescribing physician or health care provider;
108	108	and
109	109	(4) a pharmacist.
110	110	(c) A health benefit plan shall provide coverage for a
111	111	medication dispensed in accordance with the dates established in
112	112	the medication synchronization plan described by Subsection (b).
113	113	(d) A health benefit plan shall establish a process that
114	114	allows a pharmacist or pharmacy to override the health benefit
115	115	plan's denial of coverage for a medication described by Subsection
116	116	(b).
117	117	(e) A health benefit plan shall allow a pharmacist or
118	118	pharmacy to override the health benefit plan's denial of coverage
119	119	through the process described by Subsection (d), and the health
120	120	benefit plan shall provide coverage for the medication if:
121	121	(1) the prescription for the medication is being
122	122	refilled in accordance with the medication synchronization plan
123	123	described by Subsection (b); and
124	124	(2) the reason for the denial is that the prescription
125	125	is being refilled before the date established by the plan's general
126	126	prescription refill guidelines.
127	127	SECTION 2. This Act applies only to a health benefit plan
128	128	that is delivered, issued for delivery, or renewed on or after
129	129	January 1, 2016. A health benefit plan delivered, issued for
130	130	delivery, or renewed before January 1, 2016, is governed by the law
131	131	as it existed immediately before the effective date of this Act, and
132	132	that law is continued in effect for that purpose.
133	133	SECTION 3. This Act takes effect September 1, 2015.