Bill Text: TX HB2099 | 2019-2020 | 86th Legislature | Engrossed


Bill Title: Relating to modification of certain prescription drug benefits and coverage offered by certain health benefit plans.

Spectrum: Bipartisan Bill

Status: (Engrossed) 2019-05-15 - Co-sponsor authorized [HB2099 Detail]

Download: Texas-2019-HB2099-Engrossed.html
  86R13008 SMT-F
 
  By: Lambert, Sheffield, Zerwas, Oliverson, H.B. No. 2099
      Lucio III, et al.
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to modification of certain prescription drug benefits and
  coverage offered by certain health benefit plans.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 1369.0541, Insurance Code, is amended by
  amending Subsections (a) and (b) and adding Subsections (a-1) and
  (b-1) to read as follows:
         (a)  Except as provided by Section 1369.055(a-1) and
  Subsection (b-1) of this section, a [A] health benefit plan issuer
  may modify drug coverage provided under a health benefit plan if:
               (1)  the modification occurs at the time of coverage
  renewal;
               (2)  the modification is effective uniformly among all
  group health benefit plan sponsors covered by identical or
  substantially identical health benefit plans or all individuals
  covered by identical or substantially identical individual health
  benefit plans, as applicable; and
               (3)  not later than the 60th day before the date the
  modification is effective, the issuer provides written notice of
  the modification to the commissioner, each affected group health
  benefit plan sponsor, each affected enrollee in an affected group
  health benefit plan, and each affected individual health benefit
  plan holder.
         (a-1)  The notice described by Subsection (a)(3) must
  include a statement:
               (1)  indicating that the health benefit plan issuer is
  modifying drug coverage provided under the health benefit plan;
               (2)  explaining the type of modification; and
               (3)  indicating that, on renewal of the health benefit
  plan, the health benefit plan issuer may not modify an enrollee's
  contracted benefit level for any prescription drug that was
  approved or covered under the plan in the immediately preceding
  plan year as provided by Section 1369.055(a-1).
         (b)  Modifications affecting drug coverage that require
  notice under Subsection (a) include:
               (1)  removing a drug from a formulary;
               (2)  adding a requirement that an enrollee receive
  prior authorization for a drug;
               (3)  imposing or altering a quantity limit for a drug;
               (4)  imposing a step-therapy restriction for a drug;
  [and]
               (5)  moving a drug to a higher cost-sharing tier;
               (6)  increasing a coinsurance, copayment, deductible,
  or other out-of-pocket expense that an enrollee must pay for a drug;
  and
               (7)  reducing the maximum drug coverage amount [unless
  a generic drug alternative to the drug is available].
         (b-1)  Modifications affecting drug coverage that are more
  favorable to enrollees may be made at any time and do not require
  notice under Subsection (a), including:
               (1)  the addition of a drug to a formulary;
               (2)  the reduction of a coinsurance, copayment,
  deductible, or other out-of-pocket expense that an enrollee must
  pay for a drug; and
               (3)  the removal of a utilization review requirement.
         SECTION 2.  Section 1369.055, Insurance Code, is amended by
  adding Subsections (a-1), (a-2), and (c) to read as follows:
         (a-1)  On renewal of a health benefit plan, the plan issuer
  may not modify an enrollee's contracted benefit level for any
  prescription drug that was approved or covered under the plan in the
  immediately preceding plan year and prescribed during that year for
  a medical condition or mental illness of the enrollee if:
               (1)  the enrollee was covered by the health benefit
  plan on the date immediately preceding the renewal date;
               (2)  a physician or other prescribing provider
  prescribes the drug for the medical condition or mental illness;
  and
               (3)  the physician or other prescribing provider in
  consultation with the enrollee determines that the drug is the most
  appropriate course of treatment.
         (a-2)  Modifications prohibited under Subsection (a-1)
  include:
               (1)  removing a drug from a formulary;
               (2)  adding a requirement that an enrollee receive
  prior authorization for a drug;
               (3)  imposing or altering a quantity limit for a drug;
               (4)  imposing a step-therapy restriction for a drug;
               (5)  moving a drug to a higher cost-sharing tier;
               (6)  increasing a coinsurance, copayment, deductible,
  or other out-of-pocket expense that an enrollee must pay for a drug;
  and
               (7)  reducing the maximum drug coverage amount.
         (c)  Subsections (a-1) and (a-2) do not:
               (1)  prohibit a health benefit plan issuer from
  requiring, by contract, written policy or procedure, or other
  agreement or course of conduct, a pharmacist to provide a
  substitution for a prescription drug in accordance with Subchapter
  A, Chapter 562, Occupations Code, under which the pharmacist may
  substitute an interchangeable biologic product or therapeutically
  equivalent generic product as determined by the United States Food
  and Drug Administration;
               (2)  prohibit a physician or other prescribing provider
  from prescribing another medication;
               (3)  prohibit the health benefit plan issuer from
  adding a new drug to a formulary;
               (4)  require a health benefit plan to provide coverage
  to an enrollee under circumstances not described by Subsection
  (a-1); or
               (5)  prohibit a health benefit plan issuer from
  removing a drug from its formulary or denying an enrollee coverage
  for the drug if:
                     (A)  the United States Food and Drug
  Administration has issued a statement about the drug that calls
  into question the clinical safety of the drug;
                     (B)  the drug manufacturer has notified the United
  States Food and Drug Administration of a manufacturing
  discontinuance or potential discontinuance of the drug as required
  by Section 506C, Federal Food, Drug, and Cosmetic Act (21 U.S.C.
  Section 356c); or 
                     (C)  the drug manufacturer has removed the drug
  from the market.
         SECTION 3.  The changes in law made by this Act apply only to
  a health benefit plan that is delivered, issued for delivery, or
  renewed on or after January 1, 2020. A health benefit plan
  delivered, issued for delivery, or renewed before January 1, 2020,
  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, 2019.
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