Bill Text: TX SB697 | 2017-2018 | 85th Legislature | Engrossed
Bill Title: Relating to health benefit coverage for prescription drug synchronization.
Sponsorship: Slight Partisan Bill (Republican 5-2)
Status: (Engrossed - Dead) 2017-05-09 - Referred to Insurance [SB697 Detail]
Download: Texas-2017-SB697-Engrossed.html
| By: Buckingham, et al. | S.B. No. 697 | |
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| 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. | ||
