HB3542 - Relating to the effect of a pharmacy benefit manager change on prescription drug coverage.

  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.