TX
Texas House Bill HB2504

Texas 2021 - 87th Regular

Texas House Bill HB2504 Compare Versions

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1-87R19321 SMT-F
2- By: González of Dallas, Oliverson, H.B. No. 2504
3- Johnson of Dallas
4- Substitute the following for H.B. No. 2504:
5- By: Oliverson C.S.H.B. No. 2504
1+87R1885 SMT-F
2+ By: González of Dallas H.B. No. 2504
63
74
85 A BILL TO BE ENTITLED
96 AN ACT
10- relating to step therapy protocols required by health benefit plans
11- for coverage of prescription drugs for serious mental illnesses.
7+ relating to health benefit plan coverage of prescription drugs for
8+ serious mental illnesses.
129 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
13- SECTION 1. Subchapter B, Chapter 1369, Insurance Code, is
14- amended by adding Section 1369.0547 to read as follows:
15- Sec. 1369.0547. STEP THERAPY PROTOCOLS FOR PRESCRIPTION
16- DRUGS TO TREAT SERIOUS MENTAL ILLNESSES. (a) In this section,
17- "serious mental illness" has the meaning assigned by Section
18- 1355.001.
19- (b) This section applies only to a drug prescribed to an
20- enrollee who is 18 years of age or older to treat a diagnosis of a
21- serious mental illness.
22- (c) A health benefit plan that provides coverage for
23- prescription drugs to treat a serious mental illness may not
10+ SECTION 1. Chapter 1369, Insurance Code, is amended by
11+ adding Subchapter E-2 to read as follows:
12+ SUBCHAPTER E-2. PRESCRIPTION DRUG COVERAGE FOR SERIOUS MENTAL
13+ ILLNESSES
14+ Sec. 1369.221. DEFINITION. In this subchapter, "serious
15+ mental illness" has the meaning assigned by Section 1355.001.
16+ Sec. 1369.222. APPLICABILITY OF SUBCHAPTER. (a) This
17+ subchapter applies only to a health benefit plan that provides
18+ benefits for medical or surgical expenses incurred as a result of a
19+ health condition, accident, or sickness, including an individual,
20+ group, blanket, or franchise insurance policy or insurance
21+ agreement, a group hospital service contract, or an individual or
22+ group contract or similar coverage document that is issued by:
23+ (1) an insurance company;
24+ (2) a group hospital service corporation operating
25+ under Chapter 842;
26+ (3) a health maintenance organization operating under
27+ Chapter 843;
28+ (4) an approved nonprofit health corporation that
29+ holds a certificate of authority under Chapter 844;
30+ (5) a multiple employer welfare arrangement that holds
31+ a certificate of authority under Chapter 846;
32+ (6) a stipulated premium company operating under
33+ Chapter 884;
34+ (7) a fraternal benefit society operating under
35+ Chapter 885;
36+ (8) a Lloyd's plan operating under Chapter 941; or
37+ (9) a reciprocal exchange operating under Chapter 942.
38+ (b) Notwithstanding any other law, this subchapter applies
39+ to:
40+ (1) a small employer health benefit plan subject to
41+ Chapter 1501, including coverage provided through a health group
42+ cooperative under Subchapter B of that chapter;
43+ (2) a standard health benefit plan issued under
44+ Chapter 1507;
45+ (3) a basic coverage plan under Chapter 1551;
46+ (4) a basic plan under Chapter 1575;
47+ (5) a primary care coverage plan under Chapter 1579;
48+ (6) a plan providing basic coverage under Chapter
49+ 1601;
50+ (7) health benefits provided by or through a church
51+ benefits board under Subchapter I, Chapter 22, Business
52+ Organizations Code;
53+ (8) group health coverage made available by a school
54+ district in accordance with Section 22.004, Education Code;
55+ (9) a regional or local health care program operated
56+ under Section 75.104, Health and Safety Code; and
57+ (10) a self-funded health benefit plan sponsored by a
58+ professional employer organization under Chapter 91, Labor Code.
59+ (c) This subchapter applies to coverage under a group health
60+ benefit plan provided to a resident of this state regardless of
61+ whether the group policy, agreement, or contract is delivered,
62+ issued for delivery, or renewed in this state.
63+ Sec. 1369.223. PROHIBITED CONDUCT. (a) A health benefit
64+ plan that provides coverage for a serious mental illness may not
2465 require, before the health benefit plan provides coverage of a
2566 prescription drug approved by the United States Food and Drug
2667 Administration, that the enrollee:
27- (1) fail to successfully respond to more than one
28- different drug for each drug prescribed, excluding the generic or
29- brand name equivalent of the prescribed drug; or
30- (2) prove a history of failure of more than one
31- different drug for each drug prescribed, excluding the generic or
32- brand name equivalent of the prescribed drug.
33- (d) Subject to Section 1369.0546, a health benefit plan
34- issuer may implement a step therapy protocol to require a trial of a
35- generic or brand name equivalent of a prescribed prescription drug
36- as a condition of continued coverage of the prescribed drug only:
37- (1) once in a plan year; and
38- (2) if the equivalent drug is added to the plan's drug
39- formulary.
68+ (1) fail to successfully respond to a different drug;
69+ or
70+ (2) prove a history of failure of a different drug.
71+ (b) This section applies only to a drug the use of which is:
72+ (1) prescribed by a physician or other health care
73+ provider for the serious mental illness;
74+ (2) determined by the prescribing physician or health
75+ care provider in consultation with the enrollee as the most
76+ appropriate course of treatment for the serious mental illness; and
77+ (3) approved by the United States Food and Drug
78+ Administration.
79+ (c) This section applies only to a drug prescribed to an
80+ enrollee who is 18 years of age or older.
81+ (d) This section does not affect a pharmacist's authority to
82+ substitute a generic equivalent or one or more interchangeable
83+ biological products under Section 562.008, Occupations Code, for a
84+ prescription drug prescribed for a serious mental illness.
4085 SECTION 2. This Act applies only to a health benefit plan
4186 delivered, issued for delivery, or renewed on or after January 1,
4287 2022. A health benefit plan delivered, issued for delivery, or
4388 renewed before January 1, 2022, is governed by the law as it existed
4489 immediately before the effective date of this Act, and that law is
4590 continued in effect for that purpose.
4691 SECTION 3. This Act takes effect September 1, 2021.