Texas 2019 - 86th Regular

Texas House Bill HB2099 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1	1		86R13008 SMT-F
2	2		By: Lambert, Sheffield, Zerwas, Oliverson, H.B. No. 2099
3	3		Lucio III, et al.
	4	+	Substitute the following for H.B. No. 2099:
	5	+	By: Lucio III C.S.H.B. No. 2099
4	6
5	7
6	8		A BILL TO BE ENTITLED
7	9		AN ACT
8	10		relating to modification of certain prescription drug benefits and
9	11		coverage offered by certain health benefit plans.
10	12		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
11	13		SECTION 1. Section 1369.0541, Insurance Code, is amended by
12	14		amending Subsections (a) and (b) and adding Subsections (a-1) and
13	15		(b-1) to read as follows:
14	16		(a) Except as provided by Section 1369.055(a-1) and
15	17		Subsection (b-1) of this section, a [A] health benefit plan issuer
16	18		may modify drug coverage provided under a health benefit plan if:
17	19		(1) the modification occurs at the time of coverage
18	20		renewal;
19	21		(2) the modification is effective uniformly among all
20	22		group health benefit plan sponsors covered by identical or
21	23		substantially identical health benefit plans or all individuals
22	24		covered by identical or substantially identical individual health
23	25		benefit plans, as applicable; and
24	26		(3) not later than the 60th day before the date the
25	27		modification is effective, the issuer provides written notice of
26	28		the modification to the commissioner, each affected group health
27	29		benefit plan sponsor, each affected enrollee in an affected group
28	30		health benefit plan, and each affected individual health benefit
29	31		plan holder.
30	32		(a-1) The notice described by Subsection (a)(3) must
31	33		include a statement:
32	34		(1) indicating that the health benefit plan issuer is
33	35		modifying drug coverage provided under the health benefit plan;
34	36		(2) explaining the type of modification; and
35	37		(3) indicating that, on renewal of the health benefit
36	38		plan, the health benefit plan issuer may not modify an enrollee's
37	39		contracted benefit level for any prescription drug that was
38	40		approved or covered under the plan in the immediately preceding
39	41		plan year as provided by Section 1369.055(a-1).
40	42		(b) Modifications affecting drug coverage that require
41	43		notice under Subsection (a) include:
42	44		(1) removing a drug from a formulary;
43	45		(2) adding a requirement that an enrollee receive
44	46		prior authorization for a drug;
45	47		(3) imposing or altering a quantity limit for a drug;
46	48		(4) imposing a step-therapy restriction for a drug;
47	49		[and]
48	50		(5) moving a drug to a higher cost-sharing tier;
49	51		(6) increasing a coinsurance, copayment, deductible,
50	52		or other out-of-pocket expense that an enrollee must pay for a drug;
51	53		and
52	54		(7) reducing the maximum drug coverage amount [unless
53	55		a generic drug alternative to the drug is available].
54	56		(b-1) Modifications affecting drug coverage that are more
55	57		favorable to enrollees may be made at any time and do not require
56	58		notice under Subsection (a), including:
57	59		(1) the addition of a drug to a formulary;
58	60		(2) the reduction of a coinsurance, copayment,
59	61		deductible, or other out-of-pocket expense that an enrollee must
60	62		pay for a drug; and
61	63		(3) the removal of a utilization review requirement.
62	64		SECTION 2. Section 1369.055, Insurance Code, is amended by
63	65		adding Subsections (a-1), (a-2), and (c) to read as follows:
64	66		(a-1) On renewal of a health benefit plan, the plan issuer
65	67		may not modify an enrollee's contracted benefit level for any
66	68		prescription drug that was approved or covered under the plan in the
67	69		immediately preceding plan year and prescribed during that year for
68	70		a medical condition or mental illness of the enrollee if:
69	71		(1) the enrollee was covered by the health benefit
70	72		plan on the date immediately preceding the renewal date;
71	73		(2) a physician or other prescribing provider
72	74		prescribes the drug for the medical condition or mental illness;
73	75		and
74	76		(3) the physician or other prescribing provider in
75	77		consultation with the enrollee determines that the drug is the most
76	78		appropriate course of treatment.
77	79		(a-2) Modifications prohibited under Subsection (a-1)
78	80		include:
79	81		(1) removing a drug from a formulary;
80	82		(2) adding a requirement that an enrollee receive
81	83		prior authorization for a drug;
82	84		(3) imposing or altering a quantity limit for a drug;
83	85		(4) imposing a step-therapy restriction for a drug;
84	86		(5) moving a drug to a higher cost-sharing tier;
85	87		(6) increasing a coinsurance, copayment, deductible,
86	88		or other out-of-pocket expense that an enrollee must pay for a drug;
87	89		and
88	90		(7) reducing the maximum drug coverage amount.
89	91		(c) Subsections (a-1) and (a-2) do not:
90	92		(1) prohibit a health benefit plan issuer from
91	93		requiring, by contract, written policy or procedure, or other
92	94		agreement or course of conduct, a pharmacist to provide a
93	95		substitution for a prescription drug in accordance with Subchapter
94	96		A, Chapter 562, Occupations Code, under which the pharmacist may
95	97		substitute an interchangeable biologic product or therapeutically
96	98		equivalent generic product as determined by the United States Food
97	99		and Drug Administration;
98	100		(2) prohibit a physician or other prescribing provider
99	101		from prescribing another medication;
100	102		(3) prohibit the health benefit plan issuer from
101	103		adding a new drug to a formulary;
102	104		(4) require a health benefit plan to provide coverage
103	105		to an enrollee under circumstances not described by Subsection
104	106		(a-1); or
105	107		(5) prohibit a health benefit plan issuer from
106	108		removing a drug from its formulary or denying an enrollee coverage
107	109		for the drug if:
108	110		(A) the United States Food and Drug
109	111		Administration has issued a statement about the drug that calls
110	112		into question the clinical safety of the drug;
111	113		(B) the drug manufacturer has notified the United
112	114		States Food and Drug Administration of a manufacturing
113	115		discontinuance or potential discontinuance of the drug as required
114	116		by Section 506C, Federal Food, Drug, and Cosmetic Act (21 U.S.C.
115	117		Section 356c); or
116	118		(C) the drug manufacturer has removed the drug
117	119		from the market.
118	120		SECTION 3. The changes in law made by this Act apply only to
119	121		a health benefit plan that is delivered, issued for delivery, or
120	122		renewed on or after January 1, 2020. A health benefit plan
121	123		delivered, issued for delivery, or renewed before January 1, 2020,
122	124		is governed by the law as it existed immediately before the
123	125		effective date of this Act, and that law is continued in effect for
124	126		that purpose.
125	127		SECTION 4. This Act takes effect September 1, 2019.