S.B. No. 827
AN ACT
relating to health benefit plan cost-sharing requirements for
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. 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 a small or large
employer group contract or similar coverage document that is
offered by:
(1) an insurance company;
(2) a group hospital service corporation operating
under Chapter 842;
(3) a fraternal benefit society operating under
Chapter 885;
(4) a stipulated premium company operating under
Chapter 884;
(5) a reciprocal exchange operating under Chapter 942;
(6) a health maintenance organization operating under
Chapter 843;
(7) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846; or
(8) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844.
(b) This subchapter applies to group health coverage made
available by a school district in accordance with Section 22.004,
Education Code.
(c) Notwithstanding any provision in Chapter 1551, 1575,
1579, or 1601 or any other law, this subchapter applies to:
(1) a basic coverage plan under Chapter 1551;
(2) a basic plan under Chapter 1575;
(3) a primary care coverage plan under Chapter 1579;
and
(4) basic coverage under Chapter 1601.
(d) Notwithstanding any other law, this subchapter applies
to coverage under:
(1) the child health plan program under Chapter 62,
Health and Safety Code, or the health benefits plan for children
under Chapter 63, Health and Safety Code; and
(2) the medical assistance program under Chapter 32,
Human Resources Code.
Sec. 1358.102. EXCEPTION. This subchapter does not apply
to:
(1) a health benefit plan that provides coverage:
(A) only for a specified disease or for another
single benefit;
(B) only for accidental death or dismemberment;
(C) for wages or payments in lieu of wages for a
period during which an employee is absent from work because of
sickness or injury;
(D) as a supplement to a liability insurance
policy;
(E) for credit insurance;
(F) only for dental or vision care;
(G) only for hospital expenses; or
(H) only for indemnity for hospital confinement;
(2) a Medicare supplemental policy as defined by
Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
(3) medical payment insurance coverage provided under
a motor vehicle insurance policy;
(4) a long-term care insurance policy, including a
nursing home fixed indemnity policy, unless the commissioner
determines that the policy provides benefit coverage so
comprehensive that the policy is a health benefit plan as described
by Section 1358.101;
(5) health and accident coverage provided by a risk
pool created under Chapter 172, Local Government Code; or
(6) a workers' compensation insurance policy.
Sec. 1358.103. LIMIT ON COST-SHARING REQUIREMENT. (a) In
this section, "insulin" means a prescription drug that contains
insulin and is used to treat diabetes. The term does not include an
insulin drug that is administered to a patient intravenously.
(b) A health benefit plan may not impose a cost-sharing
provision for insulin that is included in the health benefit plan's
formulary if the total amount the enrollee is required to pay
exceeds $25 per prescription for a 30-day supply, regardless of the
amount or type of insulin needed to fill the enrollee's
prescription.
Sec. 1358.104. FORMULARY REQUIREMENT. A health benefit
plan must include at least one insulin from each therapeutic class
in the plan's formulary.
SECTION 2. The changes in law made by this Act apply 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.
SECTION 3. This Act takes effect September 1, 2021.
______________________________ ______________________________
President of the Senate Speaker of the House
I hereby certify that S.B. No. 827 passed the Senate on
March 25, 2021, by the following vote: Yeas 27, Nays 3; and that
the Senate concurred in House amendment on May 27, 2021, by the
following vote: Yeas 28, Nays 3.
______________________________
Secretary of the Senate
I hereby certify that S.B. No. 827 passed the House, with
amendment, on May 24, 2021, by the following vote: Yeas 140,
Nays 5, one present not voting.
______________________________
Chief Clerk of the House
Approved:
______________________________
Date
______________________________
Governor