HB4674 - Relating to modification of certain prescription drug benefits and coverage offered by certain health benefit plans.

  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.