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  S.B. No. 644
 
 
 
 
AN ACT
  relating to the creation of a standard request form for prior
  authorization of prescription drug benefits.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Chapter 1369, Insurance Code, is amended by
  adding Subchapter F to read as follows:
  SUBCHAPTER F. STANDARD REQUEST FORM FOR PRIOR AUTHORIZATION OF
  PRESCRIPTION DRUG BENEFITS
         Sec. 1369.251.  DEFINITION. In this subchapter,
  "prescription drug" has the meaning assigned by Section 551.003,
  Occupations Code.
         Sec. 1369.252.  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 a small or large
  employer group contract or similar coverage document that is
  offered by:
               (1)  an insurance company;
               (2)  a group hospital service corporation operating
  under Chapter 842;
               (3)  a fraternal benefit society operating under
  Chapter 885;
               (4)  a stipulated premium company operating under
  Chapter 884;
               (5)  a reciprocal exchange operating under Chapter 942;
               (6)  a health maintenance organization operating under
  Chapter 843;
               (7)  a multiple employer welfare arrangement that holds
  a certificate of authority under Chapter 846; or
               (8)  an approved nonprofit health corporation that
  holds a certificate of authority under Chapter 844.
         (b)  This subchapter applies to group health coverage made
  available by a school district in accordance with Section 22.004,
  Education Code.
         (c)  Notwithstanding any provision in Chapter 1551, 1575,
  1579, or 1601 or any other law, this subchapter applies to:
               (1)  a basic coverage plan under Chapter 1551;
               (2)  a basic plan under Chapter 1575;
               (3)  a primary care coverage plan under Chapter 1579;
  and
               (4)  basic coverage under Chapter 1601.
         (d)  Notwithstanding any other law, this subchapter applies
  to coverage under:
               (1)  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; and
               (2)  the medical assistance program under Chapter 32,
  Human Resources Code.
         Sec. 1369.253.  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);
               (3)  medical payment insurance coverage provided under
  a motor vehicle insurance policy;
               (4)  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 1369.252;
               (5)  health and accident coverage provided by a risk
  pool created under Chapter 172, Local Government Code; or
               (6)  a workers' compensation insurance policy.
         Sec. 1369.254.  STANDARD FORM. (a)  The commissioner by
  rule shall:
               (1)  prescribe a single, standard form for requesting
  prior authorization of prescription drug benefits;
               (2)  require a health benefit plan issuer or the agent
  of the health benefit plan issuer that manages or administers
  prescription drug benefits to use the form for any prior
  authorization of prescription drug benefits required by the plan;
               (3)  require that the department and a health benefit
  plan issuer or the agent of the health benefit plan issuer that
  manages or administers prescription drug benefits make the form
  available electronically on the website of:
                     (A)  the department;
                     (B)  the health benefit plan issuer; and
                     (C)  the agent of the health benefit plan issuer;
  and
               (4)  establish penalties for failure to accept the form
  and acknowledge receipt of the form as required by commissioner
  rule.
         (b)  Not later than the second anniversary of the date
  national standards for electronic prior authorization of benefits
  are adopted, a health benefit plan issuer or the agent of the health
  benefit plan issuer that manages or administers prescription drug
  benefits shall exchange prior authorization requests
  electronically with a prescribing provider who has e-prescribing
  capability and who initiates a request electronically.
         (c)  In prescribing a form under this section, the
  commissioner shall:
               (1)  develop the form with input from the advisory
  committee on uniform prior authorization forms established under
  Section 1369.255; and
               (2)  take into consideration:
                     (A)  any form for requesting prior authorization
  of benefits that is widely used in this state or any form currently
  used by the department;
                     (B)  request forms for prior authorization of
  benefits established by the federal Centers for Medicare and
  Medicaid Services; and
                     (C)  national standards, or draft standards,
  pertaining to electronic prior authorization of benefits.
         Sec. 1369.255.  ADVISORY COMMITTEE ON UNIFORM PRIOR
  AUTHORIZATION FORMS. (a)  The commissioner shall appoint a
  committee to advise the commissioner on the technical, operational,
  and practical aspects of developing the single, standard prior
  authorization form required under Section 1369.254 for requesting
  prior authorization of prescription drug benefits.
         (b)  The advisory committee shall determine the following:
               (1)  a single standard form for requesting prior
  authorization of prescription drug benefits;
               (2)  the length of the standard prior authorization
  form;
               (3)  the length of time allowed for acknowledgement of
  receipt of the form by the health benefit plan issuer or the agent
  of the health benefit plan issuer that manages or administers
  prescription drug benefits;
               (4)  the acceptable methods to acknowledge receipt; and
               (5)  the penalty imposed on the health benefit plan
  issuer or the agent of the health benefit plan issuer that manages
  or administers prescription drug benefits for failure to
  acknowledge receipt of the form.
         (c)  The commissioner shall consult the advisory committee
  with respect to any rule relating to a subject described by Section
  1369.254 or this section before adopting the rule and may consult
  the committee as needed with respect to a subsequent amendment of an
  adopted rule.
         (d)  Not later than the second anniversary of the final
  approval of the standard prior authorization form, and every two
  years subsequently, the commissioner shall convene the advisory
  committee to review the standard prior authorization form, examine
  the form's effectiveness and impact on patient safety, and
  determine whether changes are needed.
         (e)  The advisory committee shall be composed of the
  commissioner of insurance or the commissioner's designee, the
  executive commissioner of the Health and Human Services Commission
  or the executive commissioner's designee, and an equal number of
  members from each of the following groups:
               (1)  physicians;
               (2)  other prescribing health care providers;
               (3)  consumers experienced with prior authorizations;
               (4)  hospitals;
               (5)  pharmacists;
               (6)  specialty pharmacies;
               (7)  pharmacy benefit managers;
               (8)  specialty drug distributors;
               (9)  health benefit plan issuers for the Texas Health
  Insurance Pool established under Chapter 1506;
               (10)  health benefit plan issuers; and
               (11)  health benefit plan networks of providers.
         (f)  A member of the advisory committee serves without
  compensation.
         (g)  Section 39.003(a) of this code and Chapter 2110,
  Government Code, do not apply to the advisory committee.
         Sec. 1369.256.  FAILURE TO USE OR ACKNOWLEDGE STANDARD FORM.
  If a health benefit plan issuer or the agent of the health benefit
  plan issuer that manages or administers prescription drug benefits
  fails to use or accept the form prescribed under this subchapter or
  fails to acknowledge the receipt of a completed form submitted by a
  prescribing provider, as required by commissioner rule, the health
  benefit plan issuer or the agent of the health benefit plan issuer
  is subject to the penalties established by the commissioner.
         SECTION 2.  Not later than January 1, 2015, the commissioner
  of insurance by rule shall prescribe a standard form under Section
  1369.254, Insurance Code, as added by this Act.
         SECTION 3.  The change in law made by this Act applies only
  to a request for prior authorization of prescription drug benefits
  made on or after September 1, 2015.  A request for prior
  authorization of prescription drug benefits made before September
  1, 2015, under a health benefit plan delivered, issued for
  delivery, or renewed before that date is governed by the law in
  effect immediately before the effective date of this Act, and that
  law is continued in effect for that purpose.
         SECTION 4.  This Act takes effect September 1, 2013.
 
 
 
 
 
  ______________________________ ______________________________
     President of the Senate Speaker of the House     
 
         I hereby certify that S.B. No. 644 passed the Senate on
  May 2, 2013, by the following vote: Yeas 31, Nays 0; and that the
  Senate concurred in House amendments on May 24, 2013, by the
  following vote: Yeas 31, Nays 0.
 
 
  ______________________________
  Secretary of the Senate    
 
         I hereby certify that S.B. No. 644 passed the House, with
  amendments, on May 21, 2013, by the following vote: Yeas 132,
  Nays 15, two present not voting.
 
 
  ______________________________
  Chief Clerk of the House   
 
 
 
  Approved:
 
  ______________________________ 
              Date
 
 
  ______________________________ 
            Governor