bill protecting drug coverage when plans switch PBMs

The text as introduced · 605 words

89R4363 SCF-D

By: Martinez
H.B. No. 3542

A BILL TO BE ENTITLED

AN ACT

relating to the effect of a pharmacy benefit manager change on

prescription drug coverage.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Chapter 1369, Insurance Code, is amended by

adding Subchapter A-1 to read as follows:

SUBCHAPTER A-1. CONTINUOUS COVERAGE REQUIREMENTS

Sec. 1369.021. DEFINITION. In this subchapter,

"prescription drug" has the meaning assigned by Section 551.003,

Occupations Code.

Sec. 1369.022. 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;

(8) a Lloyd's plan operating under Chapter 941; or

(9) an exchange operating under Chapter 942.

(b) Notwithstanding any other law, this subchapter applies

to:

(1) a small employer health benefit plan subject to

Chapter 1501, including coverage provided through a health group

cooperative under Subchapter B of that chapter;

(2) a standard health benefit plan issued under

Chapter 1507;

(3) a basic coverage plan under Chapter 1551;

(4) a basic plan under Chapter 1575;

(5) a primary care coverage plan under Chapter 1579;

(6) a plan providing basic coverage under Chapter

1601;

(7) nonprofit agricultural organization health

benefits offered by a nonprofit agricultural organization under

Chapter 1682;

(8) alternative health benefit coverage offered by a

subsidiary of the Texas Mutual Insurance Company under Subchapter

M, Chapter 2054;

(9) health benefits provided by or through a church

benefits board under Subchapter I, Chapter 22, Business

Organizations Code;

(10) group health coverage made available by a school

district in accordance with Section 22.004, Education Code;

(11) the state Medicaid program, including the

Medicaid managed care program operated under Chapter 540,

Government Code;

(12) the child health plan program under Chapter 62,

Health and Safety Code;

(13) a regional or local health care program operated

under Section 75.104, Health and Safety Code;

(14) a self-funded health benefit plan sponsored by a

professional employer organization under Chapter 91, Labor Code;

(15) county employee group health benefits provided

under Chapter 157, Local Government Code; and

(16) health and accident coverage provided by a risk

pool created under Chapter 172, Local Government Code.

Sec. 1369.023. EFFECT OF PHARMACY BENEFIT MANAGER CHANGE ON

PRESCRIPTION DRUG COVERAGE. A health benefit plan may not deny or

limit an enrollee's coverage of a prescription drug solely because

of a change in the plan's pharmacy benefit manager.

SECTION 2. If before implementing any provision of this Act

a state agency determines that a waiver or authorization from a

federal agency is necessary for implementation of that provision,

the agency affected by the provision shall request the waiver or

authorization and may delay implementing that provision until the

waiver or authorization is granted.

SECTION 3. The changes in law made by this Act apply only to

a health benefit plan delivered, issued for delivery, or renewed on

or after January 1, 2026.

SECTION 4. This Act takes effect September 1, 2025.