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.