85R22787 PMO-F
By: Frullo, Oliverson, Larson, Zerwas, H.B. No. 1296
et al.
Substitute the following for H.B. No. 1296:
By: Phillips C.S.H.B. No. 1296
A BILL TO BE ENTITLED
AN ACT
relating to health benefit coverage for prescription drug
synchronization.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 1369, Insurance Code, is amended by
adding Subchapter J to read as follows:
SUBCHAPTER J. COVERAGE RELATED TO PRESCRIPTION DRUG
SYNCHRONIZATION
Sec. 1369.451. DEFINITIONS. In this subchapter:
(1) "Cost-sharing amount" includes an amount charged
for a deductible, coinsurance, or copayment.
(2) "Health care provider" means a person who provides
health care services under a license, certificate, registration, or
other similar evidence of regulation issued by this or another
state of the United States.
(3) "Physician" means an individual licensed to
practice medicine in this or another state of the United States.
Sec. 1369.452. APPLICABILITY OF SUBCHAPTER. (a) This
subchapter applies only to a 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,
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 health maintenance organization operating under
Chapter 843;
(4) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844;
(5) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846;
(6) a stipulated premium company operating under
Chapter 884;
(7) a fraternal benefit society operating under
Chapter 885; or
(8) an exchange operating under Chapter 942.
(b) This subchapter applies to group health coverage made
available by a school district in accordance with Section 22.004,
Education Code.
(c) Notwithstanding any provision in Chapter 1551, 1575,
1579, or 1601 or any other law, this subchapter applies to health
benefit plan coverage provided under:
(1) Chapter 1551;
(2) Chapter 1575;
(3) Chapter 1579; and
(4) Chapter 1601.
(d) Notwithstanding Section 1501.251 or any other law, this
subchapter applies to coverage under a small employer health
benefit plan subject to Chapter 1501.
(e) This subchapter applies to a standard health benefit
plan issued under Chapter 1507.
(f) To the extent allowed by federal law, the child health
plan program operated under Chapter 62, Health and Safety Code, and
the state Medicaid program, including the Medicaid managed care
program operated under Chapter 533, Government Code, shall provide
the coverage required under this subchapter to a recipient.
Sec. 1369.453. APPLICABILITY TO CERTAIN MEDICATIONS. This
subchapter applies with respect to only a medication that:
(1) is covered by the enrollee's health benefit plan;
(2) meets the prior authorization criteria
specifically applicable to the medication under the health benefit
plan on the date the request for synchronization is made;
(3) is used for treatment and management of a chronic
illness, as that term is defined by Section 1369.456;
(4) may be prescribed with refills;
(5) is a formulation that can be effectively dispensed
in accordance with the medication synchronization plan described by
Section 1369.456; and
(6) is not, according to the schedules established by
the commissioner of the Department of State Health Services under
Chapter 481, Health and Safety Code:
(A) a Schedule II controlled substance; or
(B) a Schedule III controlled substance
containing hydrocodone.
Sec. 1369.454. PRORATION OF COST-SHARING AMOUNT REQUIRED.
(a) A health benefit plan that provides benefits for prescription
drugs shall prorate any cost-sharing amount charged for a partial
supply of a prescription drug if:
(1) the pharmacy or the enrollee's prescribing
physician or health care provider notifies the health benefit plan
that:
(A) the quantity dispensed is to synchronize the
dates that the pharmacy dispenses the enrollee's prescription
drugs; and
(B) the synchronization of the dates is in the
best interest of the enrollee; and
(2) the enrollee agrees to the synchronization.
(b) The proration described by Subsection (a) must be based
on the number of days' supply of the drug actually dispensed.
Sec. 1369.455. PRORATION OF DISPENSING FEE PROHIBITED. A
health benefit plan that prorates a cost-sharing amount as required
by Section 1369.454 may not prorate the fee paid to the pharmacy for
dispensing the drug for which the cost-sharing amount was prorated.
Sec. 1369.456. IMPLEMENTATION OF CERTAIN MEDICATION
SYNCHRONIZATION PLANS. (a) For the purposes of this section:
(1) "Chronic illness" means an illness or physical
condition that may be:
(A) reasonably expected to continue for an
uninterrupted period of at least three months; and
(B) controlled but not cured by medical
treatment.
(2) "Medication synchronization plan" means a plan
established for the purpose of synchronizing the filling or
refilling of multiple prescriptions.
(b) A health benefit plan shall establish a process through
which the following parties may jointly approve a medication
synchronization plan for medication to treat an enrollee's chronic
illness:
(1) the health benefit plan;
(2) the enrollee;
(3) the prescribing physician or health care provider;
and
(4) a pharmacist.
(c) A health benefit plan shall provide coverage for a
medication dispensed in accordance with the dates established in
the medication synchronization plan described by Subsection (b).
(d) A health benefit plan shall establish a process that
allows a pharmacist or pharmacy to override the health benefit
plan's denial of coverage for a medication described by Subsection
(b).
(e) A health benefit plan shall allow a pharmacist or
pharmacy to override the health benefit plan's denial of coverage
through the process described by Subsection (d), and the health
benefit plan shall provide coverage for the medication if:
(1) the prescription for the medication is being
refilled in accordance with the medication synchronization plan
described by Subsection (b); and
(2) the reason for the denial is that the prescription
is being refilled before the date established by the plan's general
prescription refill guidelines.
SECTION 2. This Act applies only to a health benefit plan
that is delivered, issued for delivery, or renewed on or after
January 1, 2018. A health benefit plan delivered, issued for
delivery, or renewed before January 1, 2018, 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 3. This Act takes effect September 1, 2017.