H.B. No. 1296

	AN ACT
	relating to health benefit coverage for prescription drug
	synchronization.
	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
	SECTION 1.  Chapter 1369, Insurance Code, is amended by
	adding Subchapter J to read as follows:
	SUBCHAPTER J. COVERAGE RELATED TO PRESCRIPTION DRUG
	SYNCHRONIZATION
	Sec. 1369.451.  DEFINITIONS. In this subchapter:
	(1)  "Cost-sharing amount" includes an amount charged
	for a deductible, coinsurance, or copayment.
	(2)  "Health care provider" means a person who provides
	health care services under a license, certificate, registration, or
	other similar evidence of regulation issued by this or another
	state of the United States.
	(3)  "Physician" means an individual licensed to
	practice medicine in this or another state of the United States.
	Sec. 1369.452.  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; or
	(8)  an exchange operating under Chapter 942.
	(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 health
	benefit plan coverage provided under:
	(1)  Chapter 1551;
	(2)  Chapter 1575;
	(3)  Chapter 1579; and
	(4)  Chapter 1601.
	(d)  Notwithstanding Section 1501.251 or any other law, this
	subchapter applies to coverage under a small employer health
	benefit plan subject to Chapter 1501.
	(e)  This subchapter applies to a standard health benefit
	plan issued under Chapter 1507.
	(f)  To the extent allowed by federal law, the child health
	plan program operated under Chapter 62, Health and Safety Code, and
	the state Medicaid program, including the Medicaid managed care
	program operated under Chapter 533, Government Code, shall provide
	the coverage required under this subchapter to a recipient.
	Sec. 1369.453.  APPLICABILITY TO CERTAIN MEDICATIONS. This
	subchapter applies with respect to only a medication that:
	(1)  is covered by the enrollee's health benefit plan;
	(2)  meets the prior authorization criteria
	specifically applicable to the medication under the health benefit
	plan on the date the request for synchronization is made;
	(3)  is used for treatment and management of a chronic
	illness, as that term is defined by Section 1369.456;
	(4)  may be prescribed with refills;
	(5)  is a formulation that can be effectively dispensed
	in accordance with the medication synchronization plan described by
	Section 1369.456; and
	(6)  is not, according to the schedules established by
	the commissioner of the Department of State Health Services under
	Chapter 481, Health and Safety Code:
	(A)  a Schedule II controlled substance; or
	(B)  a Schedule III controlled substance
	containing hydrocodone.
	Sec. 1369.454.  PRORATION OF COST-SHARING AMOUNT REQUIRED.
	(a) A health benefit plan that provides benefits for prescription
	drugs shall prorate any cost-sharing amount charged for a partial
	supply of a prescription drug if:
	(1)  the pharmacy or the enrollee's prescribing
	physician or health care provider notifies the health benefit plan
	that:
	(A)  the quantity dispensed is to synchronize the
	dates that the pharmacy dispenses the enrollee's prescription
	drugs; and
	(B)  the synchronization of the dates is in the
	best interest of the enrollee; and
	(2)  the enrollee agrees to the synchronization.
	(b)  The proration described by Subsection (a) must be based
	on the number of days' supply of the drug actually dispensed.
	Sec. 1369.455.  PRORATION OF DISPENSING FEE PROHIBITED. A
	health benefit plan that prorates a cost-sharing amount as required
	by Section 1369.454 may not prorate the fee paid to the pharmacy for
	dispensing the drug for which the cost-sharing amount was prorated.
	Sec. 1369.456.  IMPLEMENTATION OF CERTAIN MEDICATION
	SYNCHRONIZATION PLANS. (a) For the purposes of this section:
	(1)  "Chronic illness" means an illness or physical
	condition that may be:
	(A)  reasonably expected to continue for an
	uninterrupted period of at least three months; and
	(B)  controlled but not cured by medical
	treatment.
	(2)  "Medication synchronization plan" means a plan
	established for the purpose of synchronizing the filling or
	refilling of multiple prescriptions.
	(b)  A health benefit plan shall establish a process through
	which the following parties may jointly approve a medication
	synchronization plan for medication to treat an enrollee's chronic
	illness:
	(1)  the health benefit plan;
	(2)  the enrollee;
	(3)  the prescribing physician or health care provider;
	and
	(4)  a pharmacist.
	(c)  A health benefit plan shall provide coverage for a
	medication dispensed in accordance with the dates established in
	the medication synchronization plan described by Subsection (b).
	(d)  A health benefit plan shall establish a process that
	allows a pharmacist or pharmacy to override the health benefit
	plan's denial of coverage for a medication described by Subsection
	(b).
	(e)  A health benefit plan shall allow a pharmacist or
	pharmacy to override the health benefit plan's denial of coverage
	through the process described by Subsection (d), and the health
	benefit plan shall provide coverage for the medication if:
	(1)  the prescription for the medication is being
	refilled in accordance with the medication synchronization plan
	described by Subsection (b); and
	(2)  the reason for the denial is that the prescription
	is being refilled before the date established by the plan's general
	prescription refill guidelines.
	SECTION 2.  This Act applies only to a health benefit plan
	that is delivered, issued for delivery, or renewed on or after
	January 1, 2018. A health benefit plan delivered, issued for
	delivery, or renewed before January 1, 2018, 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, 2017.
	______________________________	______________________________
	President of the Senate	Speaker of the House
	I certify that H.B. No. 1296 was passed by the House on May 3,
	2017, by the following vote:  Yeas 135, Nays 12, 1 present, not
	voting.
	______________________________
	Chief Clerk of the House
	I certify that H.B. No. 1296 was passed by the Senate on May
	23, 2017, by the following vote:  Yeas 29, Nays 2.
	______________________________
	Secretary of the Senate
	APPROVED:  _____________________
	Date
	_____________________
	Governor