87R1900 SMT-F
By: Blanco S.B. No. 166
A BILL TO BE ENTITLED
AN ACT
relating to a limit on cost-sharing requirements imposed by a
health benefit plan for certain prescription insulin.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 1358, Insurance Code, is amended by
adding Subchapter C to read as follows:
SUBCHAPTER C. COST-SHARING LIMIT
Sec. 1358.101. DEFINITIONS. In this subchapter:
(1) "Insulin" means a prescription drug that contains
insulin and is used to treat diabetes.
(2) "Pharmacy benefit manager" means a person, other
than a pharmacy or pharmacist, who acts as an administrator in
connection with pharmacy benefits.
Sec. 1358.102. APPLICABILITY OF SUBCHAPTER. (a) This
subchapter applies only to a health benefit plan that provides
benefits for medical or surgical expenses incurred as a result of a
health condition, accident, or sickness, including an individual,
group, blanket, or franchise insurance policy or insurance
agreement, a group hospital service contract, or an individual or
group evidence of coverage or similar coverage document that is
issued by:
(1) an insurance company;
(2) a group hospital service corporation operating
under Chapter 842;
(3) a health maintenance organization operating under
Chapter 843;
(4) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844;
(5) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846;
(6) a stipulated premium company operating under
Chapter 884;
(7) a fraternal benefit society operating under
Chapter 885;
(8) a Lloyd's plan operating under Chapter 941; or
(9) an exchange operating under Chapter 942.
(b) Notwithstanding any other law, this subchapter applies
to:
(1) a small employer health benefit plan subject to
Chapter 1501, including coverage provided through a health group
cooperative under Subchapter B of that chapter;
(2) a standard health benefit plan issued under
Chapter 1507;
(3) a basic coverage plan under Chapter 1551;
(4) a basic plan under Chapter 1575;
(5) a primary care coverage plan under Chapter 1579;
(6) a plan providing basic coverage under Chapter
1601;
(7) health benefits provided by or through a church
benefits board under Subchapter I, Chapter 22, Business
Organizations Code;
(8) group health coverage made available by a school
district in accordance with Section 22.004, Education Code;
(9) the state Medicaid program, including the Medicaid
managed care program operated under Chapter 533, Government Code;
(10) the child health plan program under Chapter 62,
Health and Safety Code;
(11) a regional or local health care program operated
under Section 75.104, Health and Safety Code; and
(12) a self-funded health benefit plan sponsored by a
professional employer organization under Chapter 91, Labor Code.
(c) This subchapter applies to coverage under a group health
benefit plan provided to a resident of this state regardless of
whether the group policy, agreement, or contract is delivered,
issued for delivery, or renewed in this state.
Sec. 1358.103. LIMIT ON COST-SHARING REQUIREMENT. A
health benefit plan may not impose a cost-sharing provision for
insulin if the total amount the enrollee is required to pay exceeds
$25 for a 30-day supply.
Sec. 1358.104. LIMITATION ON PHARMACY CONTRACTS. A
contract between a health benefit plan issuer or pharmacy benefit
manager and a pharmacy may not contain a provision:
(1) authorizing the issuer's pharmacy benefit manager
or the pharmacy to charge an amount for insulin greater than the
amount described by Section 1358.103;
(2) requiring the pharmacy to collect an amount for
insulin greater than the amount described by Section 1358.103; or
(3) requiring an enrollee to make a cost-sharing
payment for covered insulin in an amount that exceeds the amount
described by Section 1358.103.
SECTION 2. (a) Section 1358.103, Insurance Code, as added
by this Act, applies only to a health benefit plan that is
delivered, issued for delivery, or renewed on or after January 1,
2022. A health benefit plan delivered, issued for delivery, or
renewed before January 1, 2022, 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.
(b) Section 1358.104, Insurance Code, as added by this Act,
applies only to a contract entered into or renewed on or after the
effective date of this Act.
SECTION 3. This Act takes effect September 1, 2021.