86R3299 SMT-F
By: Lambert H.B. No. 2099
A BILL TO BE ENTITLED
AN ACT
relating to modification of certain prescription drug benefits and
coverage offered by certain health benefit plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 1369.0541, Insurance Code, is amended by
amending Subsections (a) and (b) and adding Subsections (a-1) and
(b-1) to read as follows:
(a) Except as provided by Section 1369.055(a-1) and
Subsection (b-1) of this section, a [A] health benefit plan issuer
may modify drug coverage provided under a health benefit plan if:
(1) the modification occurs at the time of coverage
renewal;
(2) the modification is effective uniformly among all
group health benefit plan sponsors covered by identical or
substantially identical health benefit plans or all individuals
covered by identical or substantially identical individual health
benefit plans, as applicable; and
(3) not later than the 60th day before the date the
modification is effective, the issuer provides written notice of
the modification to the commissioner, each affected group health
benefit plan sponsor, each affected enrollee in an affected group
health benefit plan, and each affected individual health benefit
plan holder.
(a-1) The notice described by Subsection (a)(3) must
include a statement:
(1) indicating that the health benefit plan issuer is
modifying drug coverage provided under the health benefit plan;
(2) explaining the type of modification; and
(3) indicating that, on renewal of the health benefit
plan, the health benefit plan issuer may not modify an enrollee's
contracted benefit level for any prescription drug that was
approved or covered under the plan in the immediately preceding
plan year as provided by Section 1369.055(a-1).
(b) Modifications affecting drug coverage that require
notice under Subsection (a) include:
(1) removing a drug from a formulary;
(2) adding a requirement that an enrollee receive
prior authorization for a drug;
(3) imposing or altering a quantity limit for a drug;
(4) imposing a step-therapy restriction for a drug;
[and]
(5) moving a drug to a higher cost-sharing tier;
(6) increasing a coinsurance, copayment, deductible,
or other out-of-pocket expense that an enrollee must pay for a drug;
and
(7) reducing the maximum drug coverage amount [unless
a generic drug alternative to the drug is available].
(b-1) Modifications affecting drug coverage that are more
favorable to enrollees may be made at any time and do not require
notice under Subsection (a), including:
(1) the addition of a drug to a formulary;
(2) the reduction of a coinsurance, copayment,
deductible, or other out-of-pocket expense that an enrollee must
pay for a drug; and
(3) the removal of a utilization review requirement.
SECTION 2. Section 1369.055, Insurance Code, is amended by
adding Subsections (a-1) and (a-2) to read as follows:
(a-1) On renewal of a health benefit plan, the plan issuer
may not modify an enrollee's contracted benefit level for any
prescription drug that was approved or covered under the plan in the
immediately preceding plan year and prescribed during that year for
a medical condition or mental illness of the enrollee if:
(1) the enrollee was covered by the health benefit
plan on the date immediately preceding the renewal date;
(2) a physician or other prescribing provider
appropriately prescribes the drug for the medical condition or
mental illness;
(3) the prescribing provider in consultation with the
enrollee determines that the drug is the most appropriate course of
treatment; and
(4) the drug is considered safe and effective for
treating the enrollee's medical condition or mental illness.
(a-2) Modifications prohibited under Subsection (a-1)
include:
(1) removing a drug from a formulary;
(2) adding a requirement that an enrollee receive
prior authorization for a drug;
(3) imposing or altering a quantity limit for a drug;
(4) imposing a step-therapy restriction for a drug;
and
(5) moving a drug to a higher cost-sharing tier.
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 January 1, 2020. A health benefit plan
delivered, issued for delivery, or renewed before January 1, 2020,
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, 2019.