| 1 | 1 | | 88R2048 RDS-F |
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| 2 | 2 | | By: Schwertner S.B. No. 1576 |
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| 3 | 3 | | |
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| 4 | 4 | | |
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| 5 | 5 | | A BILL TO BE ENTITLED |
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| 6 | 6 | | AN ACT |
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| 7 | 7 | | relating to the effect of certain reductions in a health benefit |
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| 8 | 8 | | plan enrollee's out-of-pocket expenses for certain prescription |
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| 9 | 9 | | drugs on enrollee cost-sharing requirements. |
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| 10 | 10 | | BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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| 11 | 11 | | SECTION 1. The heading to Subchapter B, Chapter 1369, |
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| 12 | 12 | | Insurance Code, is amended to read as follows: |
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| 13 | 13 | | SUBCHAPTER B. REQUIREMENTS AFFECTING COVERAGE OF SPECIFIC |
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| 14 | 14 | | PRESCRIPTION DRUGS OR COST SHARING [SPECIFIED BY DRUG FORMULARY] |
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| 15 | 15 | | SECTION 2. Subchapter B, Chapter 1369, Insurance Code, is |
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| 16 | 16 | | amended by adding Section 1369.0542 to read as follows: |
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| 17 | 17 | | Sec. 1369.0542. EFFECT OF REDUCTIONS IN OUT-OF-POCKET |
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| 18 | 18 | | EXPENSES ON COST SHARING. (a) This section applies only to a |
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| 19 | 19 | | reduction in out-of-pocket expenses made by or on behalf of an |
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| 20 | 20 | | enrollee for a prescription drug for which: |
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| 21 | 21 | | (1) a generic equivalent does not exist; |
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| 22 | 22 | | (2) a generic equivalent does exist but the enrollee |
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| 23 | 23 | | has obtained access to the prescription drug under the enrollee's |
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| 24 | 24 | | health benefit plan using: |
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| 25 | 25 | | (A) a prior authorization process; |
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| 26 | 26 | | (B) a step therapy protocol; or |
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| 27 | 27 | | (C) the health benefit plan issuer's exceptions |
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| 28 | 28 | | and appeals process; |
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| 29 | 29 | | (3) an interchangeable biological product does not |
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| 30 | 30 | | exist; or |
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| 31 | 31 | | (4) an interchangeable biological product does exist |
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| 32 | 32 | | but the enrollee has obtained access to the prescription drug under |
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| 33 | 33 | | the enrollee's health benefit plan using: |
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| 34 | 34 | | (A) a prior authorization process; |
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| 35 | 35 | | (B) a step therapy protocol; or |
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| 36 | 36 | | (C) the health benefit plan issuer's exceptions |
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| 37 | 37 | | and appeals process. |
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| 38 | 38 | | (b) An issuer of a health benefit plan that covers |
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| 39 | 39 | | prescription drugs or a pharmacy benefit manager shall apply any |
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| 40 | 40 | | third-party payment, financial assistance, discount, product |
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| 41 | 41 | | voucher, or other reduction in out-of-pocket expenses made by or on |
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| 42 | 42 | | behalf of an enrollee for a prescription drug to the enrollee's |
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| 43 | 43 | | deductible, copayment, cost-sharing responsibility, or |
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| 44 | 44 | | out-of-pocket maximum applicable to health benefits under the |
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| 45 | 45 | | enrollee's plan. |
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| 46 | 46 | | SECTION 3. Section 1369.0542, Insurance Code, as added by |
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| 47 | 47 | | this Act, applies only to a health benefit plan that is delivered, |
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| 48 | 48 | | issued for delivery, or renewed on or after January 1, 2024. A |
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| 49 | 49 | | health benefit plan delivered, issued for delivery, or renewed |
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| 50 | 50 | | before January 1, 2024, is governed by the law as it existed |
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| 51 | 51 | | immediately before the effective date of this Act, and that law is |
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| 52 | 52 | | continued in effect for that purpose. |
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| 53 | 53 | | SECTION 4. This Act takes effect September 1, 2023. |
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