Jones Bill Locks In Coverage For Drugs You Already Take

The text as introduced · 1,221 words

89R5147 SCR-F

By: Jones of Dallas
H.B. No. 4674

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 1369.053, Insurance Code, as effective

April 1, 2025, is amended to read as follows:

Sec. 1369.053. EXCEPTION. This subchapter does not apply

to:

(1) a health benefit plan that provides coverage:

(A) only for a specified disease or for another

single benefit;

(B) only for accidental death or dismemberment;

(C) for wages or payments in lieu of wages for a

period during which an employee is absent from work because of

sickness or injury;

(D) as a supplement to a liability insurance

policy;

(E) for credit insurance;

(F) only for dental or vision care;

(G) only for hospital expenses; or

(H) only for indemnity for hospital confinement;

(2) a Medicare supplemental policy as defined by

Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss),

as amended;

(3) a workers' compensation insurance policy;

(4) medical payment insurance coverage provided under

a motor vehicle insurance policy;

(5) a long-term care insurance policy, including a

nursing home fixed indemnity policy, unless the commissioner

determines that the policy provides benefit coverage so

comprehensive that the policy is a health benefit plan as described

by Section 1369.052;

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

Health and Safety Code, or the health benefits plan for children

under Chapter 63, Health and Safety Code; [ or ]

(7) a Medicaid managed care program operated under

Chapter 540 or 540A, Government Code, as applicable, or a Medicaid

program operated under Chapter 32, Human Resources Code ; or

(8) a self-funded health benefit plan as defined by

the Employee Retirement Income Security Act of 1974 (29 U.S.C.

Section 1001 et seq.) .

SECTION 2. 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 3. 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 4. 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, 2026. A health benefit plan

delivered, issued for delivery, or renewed before January 1, 2026,

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 5. This Act takes effect September 1, 2025.