HB4673 - 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.

  89R9697 RDS-D     By: Jones of Dallas H.B. No. 4673       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.