88R22472 KBB-D
By: Smithee H.B. No. 1754
Substitute the following for H.B. No. 1754:
By: Oliverson C.S.H.B. No. 1754
A BILL TO BE ENTITLED
AN ACT
relating to the disclosure of certain prescription drug information
by a health benefit plan.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 1369, Insurance Code, is amended by
adding Subchapter B-2 to read as follows:
SUBCHAPTER B-2. DISCLOSURE OF CERTAIN PRESCRIPTION DRUG
INFORMATION SPECIFIED BY DRUG FORMULARY
Sec. 1369.091. DEFINITIONS. In this subchapter:
(1) "Cost-sharing information" means the actual
out-of-pocket amount an enrollee is required to pay a dispensing
pharmacy or prescribing provider for a prescription drug under the
enrollee's health benefit plan.
(2) "Drug formulary," "enrollee," and "prescription
drug" have the meanings assigned by Section 1369.051.
(3) "Standard API" means an application interface that
meets the requirements of an applicable American National Standards
Institute (ANSI) accredited standard to conform to standards
adopted under 45 C.F.R. Section 170.215.
Sec. 1369.092. 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) 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) nonprofit agricultural organization health
benefits offered by a nonprofit agricultural organization under
Chapter 1682;
(8) alternative health benefit coverage offered by a
subsidiary of the Texas Mutual Insurance Company under Subchapter
M, Chapter 2054;
(9) a regional or local health care program operated
under Section 75.104, Health and Safety Code; and
(10) a self-funded health benefit plan sponsored by a
professional employer organization under Chapter 91, Labor Code.
Sec. 1369.093. EXCEPTIONS TO APPLICABILITY OF SUBCHAPTER.
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 operated 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.
Sec. 1369.094. DISCLOSURE OF PRESCRIPTION DRUG
INFORMATION. (a) This section applies only with respect to a
prescription drug covered under a health benefit plan's pharmacy
benefit.
(b) A health benefit plan issuer that covers prescription
drugs shall provide information regarding a covered prescription
drug to an enrollee or the enrollee's prescribing provider on
request. The information provided must include the issuer's drug
formulary and, for the prescription drug and any formulary
alternative:
(1) the enrollee's eligibility;
(2) cost-sharing information, including any
deductible, copayment, or coinsurance, which must:
(A) be consistent with cost-sharing requirements
under the enrollee's plan;
(B) be accurate at the time the cost-sharing
information is provided; and
(C) include any variance in cost-sharing based on
the patient's preferred dispensing retail or mail-order pharmacy or
the prescribing provider; and
(3) applicable utilization management requirements.
(c) In providing the information required under Subsection
(b), a health benefit plan issuer shall:
(1) respond in real time to a request made through a
standard API;
(2) allow the use of an integrated technology or
service as necessary to provide the required information;
(3) ensure that the information provided is current no
later than one business day after the date a change is made; and
(4) provide the information if the request is made
using the drug's unique billing code and National Drug Code.
(d) A health benefit plan issuer may not:
(1) deny or delay a response to a request for
information under Subsection (b) for the purpose of blocking the
release of the information;
(2) restrict a prescribing provider from
communicating to the enrollee the information provided under
Subsection (b), information about the cash price of the drug, or any
additional information on any lower cost or clinically appropriate
alternative drug, whether or not the drug is covered under the
enrollee's plan;
(3) except as required by law, interfere with,
prevent, or materially discourage access to or the exchange or use
of the information provided under Subsection (b), including by:
(A) charging a fee to access the information;
(B) not responding to a request within the time
required by this section; or
(C) instituting a consent requirement for an
enrollee to access the information; or
(4) penalize, including by taking any action intended
to punish or discourage future similar behavior by the prescribing
provider, a prescribing provider for:
(A) disclosing the information provided under
Subsection (b); or
(B) prescribing, administering, or ordering a
lower cost or clinically appropriate alternative drug.
(e) A health benefit plan issuer with fewer than 10,000
enrollees may:
(1) register with the department to receive an
additional 12 months after the effective date of this subchapter to
comply with the requirements of this subchapter; and
(2) after the additional 12 months provided for in
Subdivision (1), request from the department a temporary exception
from one or more requirements of this section by submitting a report
to the department that demonstrates that compliance would impose an
unreasonable cost relative to the public value that would be gained
from full compliance.
SECTION 2. The changes in law made by this Act apply only to
a health benefit plan delivered, issued for delivery, or renewed on
or after January 1, 2025.
SECTION 3. This Act takes effect September 1, 2023.