Bill Text: TX HB1296 | 2017-2018 | 85th Legislature | Engrossed

NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Relating to health benefit coverage for prescription drug synchronization.

Spectrum: Moderate Partisan Bill (Republican 8-1)

Status: (Passed) 2017-06-15 - Effective on 9/1/17 [HB1296 Detail]

Download: Texas-2017-HB1296-Engrossed.html
  85R22787 PMO-F
 
  By: Frullo, Oliverson, Larson, Zerwas, H.B. No. 1296
      et al.
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to health benefit coverage for prescription drug
  synchronization.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Chapter 1369, Insurance Code, is amended by
  adding Subchapter J to read as follows:
  SUBCHAPTER J. COVERAGE RELATED TO PRESCRIPTION DRUG
  SYNCHRONIZATION
         Sec. 1369.451.  DEFINITIONS. In this subchapter:
               (1)  "Cost-sharing amount" includes an amount charged
  for a deductible, coinsurance, or copayment.
               (2)  "Health care provider" means a person who provides
  health care services under a license, certificate, registration, or
  other similar evidence of regulation issued by this or another
  state of the United States.
               (3)  "Physician" means an individual licensed to
  practice medicine in this or another state of the United States.
         Sec. 1369.452.  APPLICABILITY OF SUBCHAPTER.  (a) This
  subchapter applies only to a health benefit plan that provides
  benefits for medical or surgical expenses incurred as a result of a
  health condition, accident, or sickness, including an individual,
  group, blanket, or franchise insurance policy or insurance
  agreement, a group hospital service contract, or an individual or
  group evidence of coverage or similar coverage document that is
  offered by:
               (1)  an insurance company;
               (2)  a group hospital service corporation operating
  under Chapter 842;
               (3)  a health maintenance organization operating under
  Chapter 843;
               (4)  an approved nonprofit health corporation that
  holds a certificate of authority under Chapter 844;
               (5)  a multiple employer welfare arrangement that holds
  a certificate of authority under Chapter 846;
               (6)  a stipulated premium company operating under
  Chapter 884;
               (7)  a fraternal benefit society operating under
  Chapter 885; or
               (8)  an exchange operating under Chapter 942.
         (b)  This subchapter applies to group health coverage made
  available by a school district in accordance with Section 22.004,
  Education Code.
         (c)  Notwithstanding any provision in Chapter 1551, 1575,
  1579, or 1601 or any other law, this subchapter applies to health
  benefit plan coverage provided under:
               (1)  Chapter 1551;
               (2)  Chapter 1575;
               (3)  Chapter 1579; and
               (4)  Chapter 1601.
         (d)  Notwithstanding Section 1501.251 or any other law, this
  subchapter applies to coverage under a small employer health
  benefit plan subject to Chapter 1501.
         (e)  This subchapter applies to a standard health benefit
  plan issued under Chapter 1507.
         (f)  To the extent allowed by federal law, the child health
  plan program operated under Chapter 62, Health and Safety Code, and
  the state Medicaid program, including the Medicaid managed care
  program operated under Chapter 533, Government Code, shall provide
  the coverage required under this subchapter to a recipient.
         Sec. 1369.453.  APPLICABILITY TO CERTAIN MEDICATIONS. This
  subchapter applies with respect to only a medication that:
               (1)  is covered by the enrollee's health benefit plan;
               (2)  meets the prior authorization criteria
  specifically applicable to the medication under the health benefit
  plan on the date the request for synchronization is made;
               (3)  is used for treatment and management of a chronic
  illness, as that term is defined by Section 1369.456;
               (4)  may be prescribed with refills; 
               (5)  is a formulation that can be effectively dispensed
  in accordance with the medication synchronization plan described by
  Section 1369.456; and
               (6)  is not, according to the schedules established by
  the commissioner of the Department of State Health Services under
  Chapter 481, Health and Safety Code:
                     (A)  a Schedule II controlled substance; or
                     (B)  a Schedule III controlled substance
  containing hydrocodone.
         Sec. 1369.454.  PRORATION OF COST-SHARING AMOUNT REQUIRED.  
  (a) A health benefit plan that provides benefits for prescription
  drugs shall prorate any cost-sharing amount charged for a partial
  supply of a prescription drug if:
               (1)  the pharmacy or the enrollee's prescribing
  physician or health care provider notifies the health benefit plan
  that:
                     (A)  the quantity dispensed is to synchronize the
  dates that the pharmacy dispenses the enrollee's prescription
  drugs; and
                     (B)  the synchronization of the dates is in the
  best interest of the enrollee; and
               (2)  the enrollee agrees to the synchronization.
         (b)  The proration described by Subsection (a) must be based
  on the number of days' supply of the drug actually dispensed.
         Sec. 1369.455.  PRORATION OF DISPENSING FEE PROHIBITED. A
  health benefit plan that prorates a cost-sharing amount as required
  by Section 1369.454 may not prorate the fee paid to the pharmacy for
  dispensing the drug for which the cost-sharing amount was prorated.
         Sec. 1369.456.  IMPLEMENTATION OF CERTAIN MEDICATION
  SYNCHRONIZATION PLANS. (a) For the purposes of this section:
               (1)  "Chronic illness" means an illness or physical
  condition that may be:
                     (A)  reasonably expected to continue for an
  uninterrupted period of at least three months; and
                     (B)  controlled but not cured by medical
  treatment.
               (2)  "Medication synchronization plan" means a plan
  established for the purpose of synchronizing the filling or
  refilling of multiple prescriptions.
         (b)  A health benefit plan shall establish a process through
  which the following parties may jointly approve a medication
  synchronization plan for medication to treat an enrollee's chronic
  illness:
               (1)  the health benefit plan;
               (2)  the enrollee;
               (3)  the prescribing physician or health care provider;
  and
               (4)  a pharmacist.
         (c)  A health benefit plan shall provide coverage for a
  medication dispensed in accordance with the dates established in
  the medication synchronization plan described by Subsection (b).
         (d)  A health benefit plan shall establish a process that
  allows a pharmacist or pharmacy to override the health benefit
  plan's denial of coverage for a medication described by Subsection
  (b).
         (e)  A health benefit plan shall allow a pharmacist or
  pharmacy to override the health benefit plan's denial of coverage
  through the process described by Subsection (d), and the health
  benefit plan shall provide coverage for the medication if:
               (1)  the prescription for the medication is being
  refilled in accordance with the medication synchronization plan
  described by Subsection (b); and
               (2)  the reason for the denial is that the prescription
  is being refilled before the date established by the plan's general
  prescription refill guidelines.
         SECTION 2.  This Act applies only to a health benefit plan
  that is delivered, issued for delivery, or renewed on or after
  January 1, 2018. A health benefit plan delivered, issued for
  delivery, or renewed before January 1, 2018, 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, 2017.
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