89R9697 RDS-D
By: Hughes S.B. No. 1287
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 prescription drugs that
are essential health benefits on the enrollee's cost-sharing
requirements.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 1369.0542, Insurance Code, is amended by
amending Subsection (a) and adding Subsection (c) to read as
follows:
(a) Subsection (b) [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.
(c) An issuer of a health benefit plan that covers
prescription drugs, pharmacy benefit manager, or subcontractor
shall apply any reduction in out-of-pocket expenses made on behalf
of an enrollee for a prescription drug that is included within a
category of essential health benefits under 42 U.S.C. Section
18022(b)(1), regardless of whether the health benefit plan issuer,
pharmacy benefit manager, or subcontractor classifies the drug as
an essential health benefit, to the enrollee's deductible,
copayment, cost-sharing responsibility, or out-of-pocket maximum
applicable to health benefits under the enrollee's plan. In this
subsection, "subcontractor" means a person or entity, other than an
employee of a health benefit plan issuer or pharmacy benefit
manager, to whom the health benefit plan issuer or pharmacy benefit
manager delegates the performance of a function, activity, or
service.
SECTION 2. Section 1369.0542, Insurance Code, as amended by
this Act, applies only to a health benefit plan that is delivered,
issued for delivery, or renewed on or after January 1, 2026. A
health benefit plan delivered, issued for delivery, or renewed
before January 1, 2026, 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 3. This Act takes effect September 1, 2025.