Texas 2019 - 86th Regular

Texas Senate Bill SB580 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	86R3299 SMT-F
2	2	By: Campbell S.B. No. 580
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to modification of certain prescription drug benefits and
8	8	coverage offered by certain health benefit plans.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Section 1369.0541, Insurance Code, is amended by
11	11	amending Subsections (a) and (b) and adding Subsections (a-1) and
12	12	(b-1) to read as follows:
13	13	(a) Except as provided by Section 1369.055(a-1) and
14	14	Subsection (b-1) of this section, a [A] health benefit plan issuer
15	15	may modify drug coverage provided under a health benefit plan if:
16	16	(1) the modification occurs at the time of coverage
17	17	renewal;
18	18	(2) the modification is effective uniformly among all
19	19	group health benefit plan sponsors covered by identical or
20	20	substantially identical health benefit plans or all individuals
21	21	covered by identical or substantially identical individual health
22	22	benefit plans, as applicable; and
23	23	(3) not later than the 60th day before the date the
24	24	modification is effective, the issuer provides written notice of
25	25	the modification to the commissioner, each affected group health
26	26	benefit plan sponsor, each affected enrollee in an affected group
27	27	health benefit plan, and each affected individual health benefit
28	28	plan holder.
29	29	(a-1) The notice described by Subsection (a)(3) must
30	30	include a statement:
31	31	(1) indicating that the health benefit plan issuer is
32	32	modifying drug coverage provided under the health benefit plan;
33	33	(2) explaining the type of modification; and
34	34	(3) indicating that, on renewal of the health benefit
35	35	plan, the health benefit plan issuer may not modify an enrollee's
36	36	contracted benefit level for any prescription drug that was
37	37	approved or covered under the plan in the immediately preceding
38	38	plan year as provided by Section 1369.055(a-1).
39	39	(b) Modifications affecting drug coverage that require
40	40	notice under Subsection (a) include:
41	41	(1) removing a drug from a formulary;
42	42	(2) adding a requirement that an enrollee receive
43	43	prior authorization for a drug;
44	44	(3) imposing or altering a quantity limit for a drug;
45	45	(4) imposing a step-therapy restriction for a drug;
46	46	[and]
47	47	(5) moving a drug to a higher cost-sharing tier;
48	48	(6) increasing a coinsurance, copayment, deductible,
49	49	or other out-of-pocket expense that an enrollee must pay for a drug;
50	50	and
51	51	(7) reducing the maximum drug coverage amount [unless
52	52	a generic drug alternative to the drug is available].
53	53	(b-1) Modifications affecting drug coverage that are more
54	54	favorable to enrollees may be made at any time and do not require
55	55	notice under Subsection (a), including:
56	56	(1) the addition of a drug to a formulary;
57	57	(2) the reduction of a coinsurance, copayment,
58	58	deductible, or other out-of-pocket expense that an enrollee must
59	59	pay for a drug; and
60	60	(3) the removal of a utilization review requirement.
61	61	SECTION 2. Section 1369.055, Insurance Code, is amended by
62	62	adding Subsections (a-1) and (a-2) to read as follows:
63	63	(a-1) On renewal of a health benefit plan, the plan issuer
64	64	may not modify an enrollee's contracted benefit level for any
65	65	prescription drug that was approved or covered under the plan in the
66	66	immediately preceding plan year and prescribed during that year for
67	67	a medical condition or mental illness of the enrollee if:
68	68	(1) the enrollee was covered by the health benefit
69	69	plan on the date immediately preceding the renewal date;
70	70	(2) a physician or other prescribing provider
71	71	appropriately prescribes the drug for the medical condition or
72	72	mental illness;
73	73	(3) the prescribing provider in consultation with the
74	74	enrollee determines that the drug is the most appropriate course of
75	75	treatment; and
76	76	(4) the drug is considered safe and effective for
77	77	treating the enrollee's medical condition or mental illness.
78	78	(a-2) Modifications prohibited under Subsection (a-1)
79	79	include:
80	80	(1) removing a drug from a formulary;
81	81	(2) adding a requirement that an enrollee receive
82	82	prior authorization for a drug;
83	83	(3) imposing or altering a quantity limit for a drug;
84	84	(4) imposing a step-therapy restriction for a drug;
85	85	and
86	86	(5) moving a drug to a higher cost-sharing tier.
87	87	SECTION 3. The changes in law made by this Act apply only to
88	88	a health benefit plan that is delivered, issued for delivery, or
89	89	renewed on or after January 1, 2020. A health benefit plan
90	90	delivered, issued for delivery, or renewed before January 1, 2020,
91	91	is governed by the law as it existed immediately before the
92	92	effective date of this Act, and that law is continued in effect for
93	93	that purpose.
94	94	SECTION 4. This Act takes effect September 1, 2019.