85R5843 PMO-D
By: Seliger S.B. No. 895
A BILL TO BE ENTITLED
AN ACT
relating to the transparency of certain information related to
prescription drug coverage provided by certain health benefit
plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 1369, Insurance Code, is amended by
adding Subchapter B-1 to read as follows:
SUBCHAPTER B-1. TRANSPARENCY REQUIREMENTS FOR CERTAIN INDIVIDUAL
HEALTH BENEFIT PLANS
Sec. 1369.076. DEFINITIONS. In this subchapter, terms
defined by Subchapter B have the meanings assigned by that
subchapter.
Sec. 1369.077. APPLICABILITY OF SUBCHAPTER. This
subchapter applies only to a health benefit plan that:
(1) provides prescription drug coverage under an
individual health benefit plan to which Subchapter B applies; and
(2) uses one or more drug formularies to specify the
prescription drugs covered under the plan.
SECTION 2. Sections 1369.0542 through 1369.0544, Insurance
Code, are transferred to Subchapter B-1, Insurance Code,
redesignated as Sections 1369.078 through 1369.080, and amended to
read as follows:
Sec. 1369.078 [1369.0542]. FORMULARY INFORMATION ON
INTERNET WEBSITE. (a) A health benefit plan issuer shall display
on a public Internet website maintained by the issuer formulary
information for each of the issuer's individual health benefit
plans as required by the commissioner by rule.
(b) A direct electronic link to the formulary information
must be displayed in a conspicuous manner in the electronic summary
of benefits and coverage of each individual health benefit plan
issued by the health benefit plan issuer on the health benefit plan
issuer's Internet website. The information must be publicly
accessible to enrollees, prospective enrollees, and others without
necessity of providing a password, a user name, or personally
identifiable information.
Sec. 1369.079 [1369.0543]. FORMULARY DISCLOSURE
REQUIREMENTS. (a) The commissioner shall develop and adopt by rule
requirements to promote consistency and clarity in the disclosure
of formularies to facilitate comparison shopping among individual
health benefit plans.
(b) The requirements adopted under Subsection (a) must
apply to each prescription drug:
(1) included in a formulary and dispensed in a network
pharmacy; or
(2) covered under an individual [a] health benefit
plan and typically administered by a physician or health care
provider.
(c) The formulary disclosures must:
(1) be electronically searchable by drug name;
(2) include for each drug the information required by
Subsection (d) in the order listed in that subsection; and
(3) indicate each formulary that applies to each
individual health benefit plan issued by the issuer.
(d) The formulary disclosures must include for each drug:
(1) the cost-sharing amount for each drug, including
as applicable:
(A) the dollar amount of a copayment; or
(B) for a drug subject to coinsurance:
(i) an enrollee's cost-sharing amount
stated in dollars; or
(ii) a cost-sharing range, denoted as
follows:
(a) under $100 - $;
(b) $100-$250 - $$;
(c) $251-$500 - $$$;
(d) $501-$1,000 - $$$$; or
(e) over $1,000 - $$$$$;
(2) a disclosure of prior authorization, step therapy,
or other protocol requirements for each drug;
(3) if the individual health benefit plan uses a
tier-based formulary, the specific tier for each drug listed in the
formulary;
(4) a description of how prescription drugs will
specifically be included in or excluded from the deductible,
including a description of out-of-pocket costs for a prescription
drug that may not apply to the deductible;
(5) identification of preferred formulary drugs; and
(6) an explanation of coverage of each formulary drug.
(e) The commissioner by rule may allow an alternative method
of making disclosures required under Subsection (d)(1) relating to
cost-sharing through a web-based tool that must:
(1) be publicly accessible to enrollees, prospective
enrollees, and others without necessity of providing a password, a
user name, or personally identifiable information;
(2) allow consumers to electronically search
formulary information by the name under which the individual health
benefit plan is marketed; and
(3) be accessible through a direct link that is
displayed on each page of the formulary disclosure that lists each
drug as required under Subsection (c).
Sec. 1369.080 [1369.0544]. FORMULARY INFORMATION PROVIDED
BY TOLL-FREE TELEPHONE NUMBER. In addition to providing the
information described by Section 1369.079(d)(1) in the manner
required by Section 1369.079 [1369.0543(d)(1)], a health benefit
plan issuer may make the information available to enrollees,
prospective enrollees, and others through a toll-free telephone
number that operates at least during normal business hours.
SECTION 3. The changes in law made by this Act apply only to
a health benefit plan that is delivered, issued for delivery, or
renewed on or after September 1, 2017. A health benefit plan
delivered, issued for delivery, or renewed before September 1,
2017, 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, 2017.