H.B. No. 1647
AN ACT
relating to health benefit plan coverage of clinician-administered
drugs.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 1369, Insurance Code, is amended by
adding Subchapter Q to read as follows:
SUBCHAPTER Q. CLINICIAN-ADMINISTERED DRUGS
Sec. 1369.761. DEFINITIONS. In this subchapter:
(1) "Administer" means to directly apply a drug to the
body of a patient by injection, inhalation, ingestion, or any other
means.
(2) "Clinician-administered drug" means an outpatient
prescription drug other than a vaccine that:
(A) cannot reasonably be:
(i) self-administered by the patient to
whom the drug is prescribed; or
(ii) administered by an individual
assisting the patient with the self-administration; and
(B) is typically administered:
(i) by a physician or other health care
provider authorized under the laws of this state to administer the
drug, including when acting under a physician's delegation and
supervision; and
(ii) in a physician's office.
(3) "Health care provider" means an individual who is
licensed, certified, or otherwise authorized to provide health care
services in this state.
(4) "Physician" means an individual licensed to
practice medicine in this state.
Sec. 1369.762. 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
offered 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) group health coverage made available by a school
district in accordance with Section 22.004, Education Code;
(4) a regional or local health care program operating
under Section 75.104, Health and Safety Code; and
(5) a self-funded health benefit plan sponsored by a
professional employer organization under Chapter 91, Labor Code.
Sec. 1369.763. EXCEPTIONS TO APPLICABILITY OF SUBCHAPTER.
(a) This subchapter does not apply to an issuer or provider of
health benefits under or a pharmacy benefit manager administering
pharmacy benefits under:
(1) the state Medicaid program, including the Medicaid
managed care program under Chapter 533, Government Code;
(2) the child health plan program under Chapter 62,
Health and Safety Code;
(3) the TRICARE military health system; or
(4) a workers' compensation insurance policy or other
form of providing medical benefits under Title 5, Labor Code.
(b) This subchapter does not apply to a prescription drug
administered in a hospital, hospital facility-based practice
setting, or hospital outpatient infusion center.
Sec. 1369.764. CERTAIN LIMITATIONS ON COVERAGE OF
CLINICIAN-ADMINISTERED DRUGS PROHIBITED. (a) Subject to
Subsection (b), a health benefit plan issuer may not, for an
enrollee with a chronic, complex, rare, or life-threatening medical
condition:
(1) require clinician-administered drugs to be
dispensed only by certain pharmacies or only by pharmacies
participating in the health benefit plan issuer's network;
(2) if a clinician-administered drug is otherwise
covered, limit or exclude coverage for such drugs based on the
enrollee's choice of pharmacy or because the drug was not dispensed
by a pharmacy that participates in the health benefit plan issuer's
network;
(3) require a physician or health care provider
participating in the health benefit plan issuer's network to bill
for or be reimbursed for the delivery and administration of
clinician-administered drugs under the pharmacy benefit instead of
the medical benefit without:
(A) informed written consent of the patient; and
(B) a written attestation by the patient's
physician or health care provider that a delay in the drug's
administration will not place the patient at an increased health
risk; or
(4) require that an enrollee pay an additional fee,
higher copay, higher coinsurance, second copay, second
coinsurance, or any other price increase for
clinician-administered drugs based on the enrollee's choice of
pharmacy or because the drug was not dispensed by a pharmacy that
participates in the health benefit plan issuer's network.
(b) Subsection (a) applies only if the patient's physician
or health care provider determines that:
(1) a delay of care would make disease progression
probable; or
(2) the use of a pharmacy within the health benefit
plan issuer's network would:
(A) make death or patient harm probable;
(B) potentially cause a barrier to the patient's
adherence to or compliance with the patient's plan of care; or
(C) because of the timeliness of the delivery or
dosage requirements, necessitate delivery by a different pharmacy.
(c) Nothing in this section may be construed to:
(1) authorize a person to administer a drug when
otherwise prohibited under the laws of this state or federal law; or
(2) modify drug administration requirements under the
laws of this state, including any requirements related to
delegation and supervision of drug administration.
SECTION 2. Subchapter Q, Chapter 1369, 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,
2024.
SECTION 3. This Act takes effect September 1, 2023.
______________________________ ______________________________
President of the Senate Speaker of the House
I certify that H.B. No. 1647 was passed by the House on April
21, 2023, by the following vote: Yeas 139, Nays 1, 1 present, not
voting.
______________________________
Chief Clerk of the House
I certify that H.B. No. 1647 was passed by the Senate on May
19, 2023, by the following vote: Yeas 31, Nays 0.
______________________________
Secretary of the Senate
APPROVED: _____________________
Date
_____________________
Governor