Hughes Bill Makes Outside Drug Help Count Toward Your Deductible

The text as introduced · 426 words

89R9697 RDS-D

By: Hughes
S.B. No. 1287

A BILL TO BE ENTITLED

AN ACT

relating to the effect of certain reductions in a health benefit

plan enrollee's out-of-pocket expenses for prescription drugs that

are essential health benefits on the enrollee's cost-sharing

requirements.

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

SECTION 1. Section 1369.0542, Insurance Code, is amended by

amending Subsection (a) and adding Subsection (c) to read as

follows:

(a) Subsection (b) [ This section ] applies only to a

reduction in out-of-pocket expenses made by or on behalf of an

enrollee for a prescription drug covered by the enrollee's health

benefit plan for which:

(1) a generic equivalent does not exist;

(2) a generic equivalent does exist but the enrollee

has obtained access to the prescription drug under the enrollee's

health benefit plan using:

(A) a prior authorization process;

(B) a step therapy protocol; or

(C) the health benefit plan issuer's exceptions

and appeals process;

(3) an interchangeable biological product does not

exist; or

(4) an interchangeable biological product does exist

but the enrollee has obtained access to the prescription drug under

the enrollee's health benefit plan using:

(A) a prior authorization process;

(B) a step therapy protocol; or

(C) the health benefit plan issuer's exceptions

and appeals process.

(c) An issuer of a health benefit plan that covers

prescription drugs, pharmacy benefit manager, or subcontractor

shall apply any reduction in out-of-pocket expenses made on behalf

of an enrollee for a prescription drug that is included within a

category of essential health benefits under 42 U.S.C. Section

18022(b)(1), regardless of whether the health benefit plan issuer,

pharmacy benefit manager, or subcontractor classifies the drug as

an essential health benefit, to the enrollee's deductible,

copayment, cost-sharing responsibility, or out-of-pocket maximum

applicable to health benefits under the enrollee's plan. In this

subsection, "subcontractor" means a person or entity, other than an

employee of a health benefit plan issuer or pharmacy benefit

manager, to whom the health benefit plan issuer or pharmacy benefit

manager delegates the performance of a function, activity, or

service.

SECTION 2. Section 1369.0542, Insurance Code, as amended by

this Act, applies 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 3. This Act takes effect September 1, 2025.