By: Lucio III H.B. No. 1586
A BILL TO BE ENTITLED
AN ACT
relating to specialty prescription drug coverage.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 1369.001, Insurance Code, is amended by
adding Subsections (05) through (09) to read as follows:
(05) "Pharmacy benefit manager" has the meaning
assigned by Section 4151.151.
(06) "Pharmacy benefit contract" means an agreement
between an entity licensed under the insurance laws of this state
and an enrollee for the coverage of prescription drugs;
(07) "Prescription drug" has the meaning assigned by
Section 551.003, Occupations Code, except that the term
"prescription drug" does not include a device or an animal health
product.
(08) "Specialty drug" means a prescription drug that
is
(A) prescribed to a person with a chronic,
complex, rare, or life threatening medical condition;
(B) available in injectable, infusion,
inhalable, implantable, or oral form; and
(C) not usually self-administered by a patient.
(09) "Hospital outpatient infusion center" means a
health care facility where a patient receives infusion therapy on
an outpatient basis.
SECTION 2. Section 1369, Insurance Code, is amended by
adding Section 1369.0042 to read as follows:
Sec. 1369.0042. SPECIALTY DRUGS. (a) A health benefit plan
issuer or pharmacy benefit manager shall:
(1) permit an enrollee to obtain a specialty drug from
a physician's office or hospital outpatient infusion center that
provides and administers a specialty drug;
(2) permit a person covered under a pharmacy benefit
contract that provides coverage for prescription drugs to obtain a
specialty drug from a physician's office, or hospital outpatient
infusion center, that provides and administers the specialty drug;
(3) not limit coverage or benefits of an enrollee of a
health benefit plan or person covered under a pharmacy benefit
contract;
(4) not require an enrollee of a health benefit plan
that provides coverage for specialty drugs to pay an additional
fee, higher copay, higher coinsurance, second copay, second
coinsurance, or any other penalty, if the person obtains a
specialty drug from a physician's office, or a hospital outpatient
infusion center, that provides and administers a specialty drug;
(5) not require a person covered under a pharmacy
benefit contract that provides coverage for specialty drugs to pay
an additional fee, higher copay, higher coinsurance, second copay,
second coinsurance, or any other penalty if the person obtains a
specialty drug from a physician's office, or a hospital outpatient
infusion center, that provides and administers a specialty drug;
(6) not require a hospital, physician's office, or
hospital outpatient infusion center to obtain a specialty drug from
a participating pharmacy in the health benefit plan issuer's
network; and
(7) not, condition, deny, restrict, or otherwise
reduce payment to a hospital, pharmacy, physician's office, or
hospital outpatient infusion center for a specialty drug because a
hospital, physician's office, or hospital outpatient infusion
center obtains a specialty drug from a pharmacy that does not
participate in the health benefit plan issuer's network.
SECTION 3. This Act takes effect September 1, 2021.