88R20842 RDS-F
By: Price, Guillen, Allison, Oliverson, H.B. No. 999
et al.
A BILL TO BE ENTITLED
AN ACT
relating to the effect of certain reductions in a health benefit
plan enrollee's out-of-pocket expenses for certain prescription
drugs on enrollee cost-sharing requirements.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. The heading to Subchapter B, Chapter 1369,
Insurance Code, is amended to read as follows:
SUBCHAPTER B. REQUIREMENTS AFFECTING COVERAGE OF SPECIFIC
PRESCRIPTION DRUGS OR COST SHARING [SPECIFIED BY DRUG FORMULARY]
SECTION 2. Subchapter B, Chapter 1369, Insurance Code, is
amended by adding Section 1369.0542 to read as follows:
Sec. 1369.0542. EFFECT OF REDUCTIONS IN OUT-OF-POCKET
EXPENSES ON COST SHARING. (a) This section applies only to a
reduction in out-of-pocket expenses made by or on behalf of an
enrollee for a prescription drug covered by the enrollee's health
benefit plan for which:
(1) a generic equivalent does not exist;
(2) a generic equivalent does exist but the enrollee
has obtained access to the prescription drug under the enrollee's
health benefit plan using:
(A) a prior authorization process;
(B) a step therapy protocol; or
(C) the health benefit plan issuer's exceptions
and appeals process;
(3) an interchangeable biological product does not
exist; or
(4) an interchangeable biological product does exist
but the enrollee has obtained access to the prescription drug under
the enrollee's health benefit plan using:
(A) a prior authorization process;
(B) a step therapy protocol; or
(C) the health benefit plan issuer's exceptions
and appeals process.
(b) An issuer of a health benefit plan that covers
prescription drugs or a pharmacy benefit manager shall apply any
third-party payment, financial assistance, discount, product
voucher, or other reduction in out-of-pocket expenses made by or on
behalf of an enrollee for a prescription drug to the enrollee's
deductible, copayment, cost-sharing responsibility, or
out-of-pocket maximum applicable to health benefits under the
enrollee's plan.
SECTION 3. Section 1369.0542, 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. A
health benefit plan delivered, issued for delivery, or renewed
before January 1, 2024, 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 4. This Act takes effect September 1, 2023.