85R11447 LED-D
By: Schwertner S.B. No. 1922
A BILL TO BE ENTITLED
AN ACT
relating to prescription drug benefits in the Medicaid managed care
program.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 533, Government Code, is amended by
adding Subchapter B to read as follows:
SUBCHAPTER B. PRESCRIPTION DRUG BENEFITS
Sec. 533.051. DEFINITIONS. In this subchapter:
(1) "Labeler" and "manufacturer" have the meanings
assigned by Section 531.070.
(2) "Recipient" means a Medicaid recipient.
(3) "Step therapy protocol" means a protocol that
requires a recipient to use a prescription drug or sequence of
prescription drugs other than the drug that the recipient's
physician recommends for the recipient's treatment before a managed
care organization provides coverage for the recommended drug.
Sec. 533.052. APPLICABILITY OF SUBCHAPTER. (a) This
subchapter applies to an outpatient pharmacy benefit plan
implemented by a managed care organization that contracts with the
commission to provide health care benefits to recipients.
(b) To the extent of a conflict between the requirements for
an outpatient pharmacy benefit plan for a managed care
organization's enrolled recipients specified by Sections
533.005(a)(23)(A), (B), and (C) and the requirements for that plan
specified by this subchapter, the requirements specified by
Sections 533.005(a)(23)(A), (B), and (C) prevail. This subsection
expires August 31, 2018.
Sec. 533.053. STEP THERAPY PROTOCOL EXCEPTION REQUESTS.
(a) A managed care organization shall establish a process in a
user-friendly format through which an exception request under this
section may be submitted by a prescribing provider. The process
must be readily accessible to:
(1) a recipient who enrolls in a managed care plan
offered by the managed care organization or transfers to a managed
care plan offered by the managed care organization from a managed
care plan offered by another managed care organization; and
(2) the provider.
(b) A prescribing provider on behalf of a recipient may
submit to the recipient's managed care organization a written
request for an exception to a step therapy protocol required by the
recipient's managed care organization. The executive commissioner
by rule shall prescribe the form of the written request.
(c) A managed care organization shall grant a written
request under Subsection (b) if the request includes the
prescribing provider's written statement stating that:
(1) the drug required under the step therapy protocol:
(A) is contraindicated;
(B) will likely cause an adverse reaction in or
physical or mental harm to the recipient; or
(C) is expected to be ineffective based on the
known clinical characteristics of the recipient and the known
characteristics of the prescription drug regimen;
(2) the recipient previously discontinued taking the
drug required under the step therapy protocol, or another
prescription drug in the same pharmacologic class or with the same
mechanism of action as the required drug:
(A) while enrolled in a managed care plan offered
by the recipient's current managed care organization or while
enrolled in a managed care plan offered by another managed care
organization; and
(B) because the drug was not effective or had a
diminished effect or because of an adverse event;
(3) the drug required under the step therapy protocol
is not in the best interest of the recipient, based on clinical
appropriateness, because the recipient's use of the drug is
expected to:
(A) cause a significant barrier to the
recipient's adherence to or compliance with the recipient's plan of
care;
(B) worsen a comorbid condition of the recipient;
or
(C) decrease the recipient's ability to achieve
or maintain reasonable functional ability in performing daily
activities; or
(4) the drug that is subject to the step therapy
protocol was prescribed for the recipient's condition while
enrolled in a managed care plan offered by the recipient's current
managed care organization or while enrolled in a managed care plan
offered by a previous managed care organization and the recipient
is stable on the drug.
(d) Except as provided by Subsection (e), if a managed care
organization does not deny an exception request described by
Subsection (b) before 72 hours after the managed care organization
receives the request, the request is considered granted.
(e) If a written statement described by Subsection (c) also
states that the prescribing provider reasonably believes that
denial of the request makes the death of or serious harm to the
recipient probable, the request is considered granted if the
managed care organization does not deny the request before 24 hours
after the managed care organization receives the request.
Sec. 533.054. CONTINUITY OF CARE. A managed care
organization shall provide coverage to a recipient who enrolls in a
managed care plan offered by the managed care organization or
transfers to a managed care plan offered by the managed care
organization from a managed care plan offered by another managed
care organization for a prescription drug prescribed for the
recipient before the enrollment or transfer for a 90-day period
following the date of the enrollment or transfer, regardless of
whether the prescription drug is on the managed care organization's
preferred drug list.
Sec. 533.055. ACCESS TO INFORMATION REGARDING PRESCRIPTION
DRUG REBATES, PRICING, AND NEGOTIATIONS. (a) The commission may
require the submission of and review information obtained or
maintained by a managed care organization regarding prescription
drug rebate negotiations or a supplemental Medicaid or other rebate
agreement, including the rebate amount, rebate percentage, and
manufacturer or labeler pricing.
(b) Information described by Subsection (a) that a managed
care organization submits to the commission as required by the
commission is confidential and not subject to disclosure under
Chapter 552.
(c) Subsection (b) does not:
(1) authorize the commission to withhold from
individual members, agencies, or committees of the legislature for
use for legislative purposes information described by Subsection
(a) that a managed care organization submits to the commission; or
(2) affect the applicability of Section 552.008.
Sec. 533.056. PREFERRED DRUG LIST. A managed care
organization shall provide for the distribution of current copies
of the managed care organization's preferred drug list by posting
the list on the managed care organization's Internet website.
Sec. 533.057. PRIOR AUTHORIZATION FOR CERTAIN PRESCRIPTION
DRUGS. (a) Except as provided by Subsection (b), a managed care
organization may not require prior authorization for prescription
drugs that, as determined by the commission, are used to treat
patients with illnesses that:
(1) are life-threatening;
(2) are chronic; and
(3) require complex medical management strategies.
(b) Subsection (a) applies only to a drug that is prescribed
for a use approved by the United States Food and Drug
Administration. A managed care organization may require prior
authorization for a drug prescribed for a use that is not approved
by the United States Food and Drug Administration.
(c) Once every 10 years, the commission shall conduct a
study to evaluate and determine the classes of prescription drugs
for which prior authorizations are prohibited under Subsection (a).
(d) A managed care organization shall ensure that a drug
prescribed before the managed care organization implements a prior
authorization requirement for that drug is not subject to the prior
authorization requirement until the earlier of:
(1) the date the recipient exhausts the prescription,
including any authorized refills; or
(2) the expiration of a period specified by the
managed care organization.
SECTION 2. Not later than September 1, 2018, the Health and
Human Services Commission shall conduct the initial study required
by Section 533.057(c), Government Code, as added by this Act.
SECTION 3. If before implementing any provision of this Act
a state agency determines that a waiver or authorization from a
federal agency is necessary for implementation of that provision,
the agency affected by the provision shall request the waiver or
authorization and may delay implementing that provision until the
waiver or authorization is granted.
SECTION 4. This Act takes effect September 1, 2017.