Texas 2025 - 89th Regular

Texas Senate Bill SB959 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	89R5147 SCR-F
2	2	By: Perry S.B. No. 959
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7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to modification of certain prescription drug benefits and
10	10	coverage offered by certain health benefit plans.
11	11	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12	12	SECTION 1. Section 1369.053, Insurance Code, as effective
13	13	April 1, 2025, is amended to read as follows:
14	14	Sec. 1369.053. EXCEPTION. This subchapter does not apply
15	15	to:
16	16	(1) a health benefit plan that provides coverage:
17	17	(A) only for a specified disease or for another
18	18	single benefit;
19	19	(B) only for accidental death or dismemberment;
20	20	(C) for wages or payments in lieu of wages for a
21	21	period during which an employee is absent from work because of
22	22	sickness or injury;
23	23	(D) as a supplement to a liability insurance
24	24	policy;
25	25	(E) for credit insurance;
26	26	(F) only for dental or vision care;
27	27	(G) only for hospital expenses; or
28	28	(H) only for indemnity for hospital confinement;
29	29	(2) a Medicare supplemental policy as defined by
30	30	Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss),
31	31	as amended;
32	32	(3) a workers' compensation insurance policy;
33	33	(4) medical payment insurance coverage provided under
34	34	a motor vehicle insurance policy;
35	35	(5) a long-term care insurance policy, including a
36	36	nursing home fixed indemnity policy, unless the commissioner
37	37	determines that the policy provides benefit coverage so
38	38	comprehensive that the policy is a health benefit plan as described
39	39	by Section 1369.052;
40	40	(6) the child health plan program under Chapter 62,
41	41	Health and Safety Code, or the health benefits plan for children
42	42	under Chapter 63, Health and Safety Code; [or]
43	43	(7) a Medicaid managed care program operated under
44	44	Chapter 540 or 540A, Government Code, as applicable, or a Medicaid
45	45	program operated under Chapter 32, Human Resources Code; or
46	46	(8) a self-funded health benefit plan as defined by
47	47	the Employee Retirement Income Security Act of 1974 (29 U.S.C.
48	48	Section 1001 et seq.).
49	49	SECTION 2. Section 1369.0541, Insurance Code, is amended by
50	50	amending Subsections (a) and (b) and adding Subsections (a-1) and
51	51	(b-1) to read as follows:
52	52	(a) Except as provided by Section 1369.055(a-1) and
53	53	Subsection (b-1) of this section, a [A] health benefit plan issuer
54	54	may modify drug coverage provided under a health benefit plan if:
55	55	(1) the modification occurs at the time of coverage
56	56	renewal;
57	57	(2) the modification is effective uniformly among all
58	58	group health benefit plan sponsors covered by identical or
59	59	substantially identical health benefit plans or all individuals
60	60	covered by identical or substantially identical individual health
61	61	benefit plans, as applicable; and
62	62	(3) not later than the 60th day before the date the
63	63	modification is effective, the issuer provides written notice of
64	64	the modification to the commissioner, each affected group health
65	65	benefit plan sponsor, each affected enrollee in an affected group
66	66	health benefit plan, and each affected individual health benefit
67	67	plan holder.
68	68	(a-1) The notice described by Subsection (a)(3) must
69	69	include a statement:
70	70	(1) indicating that the health benefit plan issuer is
71	71	modifying drug coverage provided under the health benefit plan;
72	72	(2) explaining the type of modification; and
73	73	(3) indicating that, on renewal of the health benefit
74	74	plan, the health benefit plan issuer may not modify an enrollee's
75	75	contracted benefit level for any prescription drug that was
76	76	approved or covered under the plan in the immediately preceding
77	77	plan year as provided by Section 1369.055(a-1).
78	78	(b) Modifications affecting drug coverage that require
79	79	notice under Subsection (a) include:
80	80	(1) removing a drug from a formulary;
81	81	(2) adding a requirement that an enrollee receive
82	82	prior authorization for a drug;
83	83	(3) imposing or altering a quantity limit for a drug;
84	84	(4) imposing a step-therapy restriction for a drug;
85	85	[and]
86	86	(5) moving a drug to a higher cost-sharing tier;
87	87	(6) increasing a coinsurance, copayment, deductible,
88	88	or other out-of-pocket expense that an enrollee must pay for a drug;
89	89	and
90	90	(7) reducing the maximum drug coverage amount [unless
91	91	a generic drug alternative to the drug is available].
92	92	(b-1) Modifications affecting drug coverage that are more
93	93	favorable to enrollees may be made at any time and do not require
94	94	notice under Subsection (a), including:
95	95	(1) the addition of a drug to a formulary;
96	96	(2) the reduction of a coinsurance, copayment,
97	97	deductible, or other out-of-pocket expense that an enrollee must
98	98	pay for a drug; and
99	99	(3) the removal of a utilization review requirement.
100	100	SECTION 3. Section 1369.055, Insurance Code, is amended by
101	101	adding Subsections (a-1), (a-2), and (c) to read as follows:
102	102	(a-1) On renewal of a health benefit plan, the plan issuer
103	103	may not modify an enrollee's contracted benefit level for any
104	104	prescription drug that was approved or covered under the plan in the
105	105	immediately preceding plan year and prescribed during that year for
106	106	a medical condition or mental illness of the enrollee if:
107	107	(1) the enrollee was covered by the health benefit
108	108	plan on the date immediately preceding the renewal date;
109	109	(2) a physician or other prescribing provider
110	110	prescribes the drug for the medical condition or mental illness;
111	111	and
112	112	(3) the physician or other prescribing provider in
113	113	consultation with the enrollee determines that the drug is the most
114	114	appropriate course of treatment.
115	115	(a-2) Modifications prohibited under Subsection (a-1)
116	116	include:
117	117	(1) removing a drug from a formulary;
118	118	(2) adding a requirement that an enrollee receive
119	119	prior authorization for a drug;
120	120	(3) imposing or altering a quantity limit for a drug;
121	121	(4) imposing a step-therapy restriction for a drug;
122	122	(5) moving a drug to a higher cost-sharing tier;
123	123	(6) increasing a coinsurance, copayment, deductible,
124	124	or other out-of-pocket expense that an enrollee must pay for a drug;
125	125	and
126	126	(7) reducing the maximum drug coverage amount.
127	127	(c) Subsections (a-1) and (a-2) do not:
128	128	(1) prohibit a health benefit plan issuer from
129	129	requiring, by contract, written policy or procedure, or other
130	130	agreement or course of conduct, a pharmacist to provide a
131	131	substitution for a prescription drug in accordance with Subchapter
132	132	A, Chapter 562, Occupations Code, under which the pharmacist may
133	133	substitute an interchangeable biologic product or therapeutically
134	134	equivalent generic product as determined by the United States Food
135	135	and Drug Administration;
136	136	(2) prohibit a physician or other prescribing provider
137	137	from prescribing another medication;
138	138	(3) prohibit the health benefit plan issuer from
139	139	adding a new drug to a formulary;
140	140	(4) require a health benefit plan to provide coverage
141	141	to an enrollee under circumstances not described by Subsection
142	142	(a-1); or
143	143	(5) prohibit a health benefit plan issuer from
144	144	removing a drug from its formulary or denying an enrollee coverage
145	145	for the drug if:
146	146	(A) the United States Food and Drug
147	147	Administration has issued a statement about the drug that calls
148	148	into question the clinical safety of the drug;
149	149	(B) the drug manufacturer has notified the United
150	150	States Food and Drug Administration of a manufacturing
151	151	discontinuance or potential discontinuance of the drug as required
152	152	by Section 506C, Federal Food, Drug, and Cosmetic Act (21 U.S.C.
153	153	Section 356c); or
154	154	(C) the drug manufacturer has removed the drug
155	155	from the market.
156	156	SECTION 4. The changes in law made by this Act apply only to
157	157	a health benefit plan that is delivered, issued for delivery, or
158	158	renewed on or after January 1, 2026. A health benefit plan
159	159	delivered, issued for delivery, or renewed before January 1, 2026,
160	160	is governed by the law as it existed immediately before the
161	161	effective date of this Act, and that law is continued in effect for
162	162	that purpose.
163	163	SECTION 5. This Act takes effect September 1, 2025.