| 1 | 1 | | 89R9697 RDS-D |
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| 2 | 2 | | By: Hughes S.B. No. 1287 |
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| 3 | 3 | | |
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| 4 | 4 | | |
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| 5 | 5 | | |
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| 6 | 6 | | |
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| 7 | 7 | | A BILL TO BE ENTITLED |
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| 8 | 8 | | AN ACT |
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| 9 | 9 | | relating to the effect of certain reductions in a health benefit |
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| 10 | 10 | | plan enrollee's out-of-pocket expenses for prescription drugs that |
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| 11 | 11 | | are essential health benefits on the enrollee's cost-sharing |
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| 12 | 12 | | requirements. |
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| 13 | 13 | | BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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| 14 | 14 | | SECTION 1. Section 1369.0542, Insurance Code, is amended by |
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| 15 | 15 | | amending Subsection (a) and adding Subsection (c) to read as |
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| 16 | 16 | | follows: |
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| 17 | 17 | | (a) Subsection (b) [This section] applies only to a |
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| 18 | 18 | | reduction in out-of-pocket expenses made by or on behalf of an |
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| 19 | 19 | | enrollee for a prescription drug covered by the enrollee's health |
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| 20 | 20 | | benefit plan 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 | | (c) An issuer of a health benefit plan that covers |
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| 39 | 39 | | prescription drugs, pharmacy benefit manager, or subcontractor |
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| 40 | 40 | | shall apply any reduction in out-of-pocket expenses made on behalf |
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| 41 | 41 | | of an enrollee for a prescription drug that is included within a |
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| 42 | 42 | | category of essential health benefits under 42 U.S.C. Section |
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| 43 | 43 | | 18022(b)(1), regardless of whether the health benefit plan issuer, |
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| 44 | 44 | | pharmacy benefit manager, or subcontractor classifies the drug as |
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| 45 | 45 | | an essential health benefit, to the enrollee's deductible, |
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| 46 | 46 | | copayment, cost-sharing responsibility, or out-of-pocket maximum |
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| 47 | 47 | | applicable to health benefits under the enrollee's plan. In this |
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| 48 | 48 | | subsection, "subcontractor" means a person or entity, other than an |
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| 49 | 49 | | employee of a health benefit plan issuer or pharmacy benefit |
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| 50 | 50 | | manager, to whom the health benefit plan issuer or pharmacy benefit |
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| 51 | 51 | | manager delegates the performance of a function, activity, or |
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| 52 | 52 | | service. |
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| 53 | 53 | | SECTION 2. Section 1369.0542, Insurance Code, as amended by |
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| 54 | 54 | | this Act, applies only to a health benefit plan that is delivered, |
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| 55 | 55 | | issued for delivery, or renewed on or after January 1, 2026. A |
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| 56 | 56 | | health benefit plan delivered, issued for delivery, or renewed |
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| 57 | 57 | | before January 1, 2026, is governed by the law as it existed |
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| 58 | 58 | | immediately before the effective date of this Act, and that law is |
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| 59 | 59 | | continued in effect for that purpose. |
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| 60 | 60 | | SECTION 3. This Act takes effect September 1, 2025. |
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