80C60(2) KCR

 

SECTION ____.  CONFORMING AMENDMENT.  Subchapter C, Chapter 1579, Insurance Code, is amended by adding Sections 1579.106, 1579.107, and 1579.108 to read as follows:

Sec. 1579.106.  PRIOR AUTHORIZATION FOR CERTAIN DRUGS.  (a)  In this section, "drug formulary" means a list of drugs preferred for use and eligible for coverage by a health coverage plan.

(b)  A health coverage plan provided under this chapter that uses a drug formulary in providing a prescription drug benefit must require prior authorization for coverage of the following categories of prescribed drugs if the specific drug prescribed is not included in the formulary:

(1)  a gastrointestinal drug;

(2)  a cholesterol-lowering drug;

(3)  an anti-inflammatory drug;

(4)  an antihistamine drug; and

(5)  an antidepressant drug.

(c)  Every six months the trustee shall submit to the comptroller and the Legislative Budget Board a report regarding any cost savings achieved in the program through implementation of the prior authorization requirement of this section.  The report must cover the previous six-month period.  (V.T.I.C. Art. 3.50-7A, as added Acts 78th Leg., R.S., Ch. 213.)

Source Law

Art. 3.50-7A.  (a)  In this article, "drug formulary" means a list of drugs preferred for use and eligible for coverage by a health coverage plan.

(b)  A health coverage plan provided under the uniform group coverage program established under Article 3.50-7 of this code that uses a drug formulary in providing a prescription drug benefit must require prior authorization for coverage of the following categories of prescribed drugs if the specific drug prescribed is not included in the formulary:

(1)  a gastrointestinal drug;

(2)  a cholesterol-lowering drug;

(3)  an anti-inflammatory drug;

(4)  an antihistamine drug; and

(5)  an antidepressant drug.

(c)  Every six months the Teacher Retirement System of Texas shall submit to the comptroller and Legislative Budget Board a report regarding any cost savings achieved in the uniform group coverage program through implementation of the prior authorization requirement of this article.  A report must cover the previous six-month period.

Revisor's Note

(1)  Section (b), V.T.I.C. Article 3.50-7A, as added by Chapter 213, Acts of the 78th Legislature, Regular Session, 2003, refers to a "health coverage plan provided under the uniform group coverage program established under Article 3.50-7 of this code."  Section (c) of that article also refers to the "uniform group coverage program" established under Article 3.50-7.  V.T.I.C. Article 3.50-7 was codified in 2003 as Chapter 1579, Insurance Code.  For that reason, throughout Sections 1579.106-1579.108, the revised law substitutes "this chapter" for a reference to Article 3.50-7.  The revised law also omits as unnecessary the reference to the health coverage plan being provided under "the uniform group coverage program established under Article 3.50-7" because only health coverage plans provided under the uniform group coverage program formerly governed by Article 3.50-7A are governed by Chapter 1579.  Because Section 1579.002 of this code defines "program" for purposes of Chapter 1579 as the uniform group coverage program established under Chapter 1579, the revised law also substitutes "program" for "uniform group coverage program."

(2)  Section (c), V.T.I.C. Article 3.50-7A, as added by Chapter 213, Acts of the 78th Legislature, Regular Session, 2003, refers to the "Teacher Retirement System of Texas."  Section 1579.002 of this code defines "trustee" for purposes of Chapter 1579 as the Teacher Retirement System of Texas.  For that reason, throughout Sections 1579.106-1579.108, the revised law substitutes "trustee" for "Teacher Retirement System of Texas."

Revised Law

Sec. 1579.107.  DISEASE MANAGEMENT SERVICES.  (a)  In this section, "disease management services" means services to assist an individual manage a disease or other chronic health condition, such as heart disease, diabetes, respiratory illness, end-stage renal disease, HIV infection, or AIDS, and with respect to which the trustee identifies populations requiring disease management.

(b)  A health coverage plan provided under this chapter must provide disease management services or coverage for disease management services in the manner required by the trustee, including:

(1)  patient self-management education;

(2)  provider education;

(3)  evidence-based models and minimum standards of care;

(4)  standardized protocols and participation criteria; and

(5)  physician-directed or physician-supervised care.  (V.T.I.C. Art. 3.50-7B.)

Source Law

Art. 3.50-7B.  (a)  In this article, "disease management services" means services to assist an individual manage a disease or other chronic health condition, such as heart disease, diabetes, respiratory illness, end-stage renal disease, HIV infection, or AIDS, and with respect to which the Teacher Retirement System of Texas identifies populations requiring disease management.

(b)  A health coverage plan provided under Article 3.50-7 of this code must provide disease management services or coverage for disease management services in the manner required by the Teacher Retirement System of Texas, including:

(1)  patient self-management education;

(2)  provider education;

(3)  evidence-based models and minimum standards of care;

(4)  standardized protocols and participation criteria; and

(5)  physician-directed or physician-supervised care.

Revised Law

Sec. 1579.108.  LIMITATIONS.  The trustee may not contract for or provide a health coverage plan that excludes from participation in the network a general hospital that:

(1)  is located in the geographical service area or areas of the health coverage plan that includes a county that:

(A)  has a population of at least 100,000 and not more than 175,000; and

(B)  is located in the Texas-Louisiana border region, as that term is defined in Section 2056.002(e), Government Code; and

(2)  agrees to provide medical and health care services under the plan subject to the same terms as other hospital providers under the plan.  (V.T.I.C. Art. 3.50-7A, Sec. (b), as added Acts 78th Leg., R.S., Ch. 201.)

Source Law

(b)  The Teacher Retirement System of Texas, as trustee, may not contract for or provide a health coverage plan that excludes from participation in the network a general hospital that:

(1)  is located in within the geographical service area or areas of the health coverage plan that includes a county that:

(A)  has a population of at least 100,000 and not more than 175,000; and

(B)  is located in the Texas-Louisiana border region, as that term is defined in Section 2056.002(e), Government Code; and

(2)  agrees to provide medical and health care services under the plan subject to the same terms and conditions as other hospital providers under the plan.

Revisor's Note

(1)  Section (a), V.T.I.C. Article 3.50-7A, as added by Chapter 201, Acts of the 78th Legislature, Regular Session, 2003, provides that the article applies only to the uniform group coverage program established under V.T.I.C. Article 3.50-7 and that a term used in V.T.I.C. Article 3.50-7A has the meaning assigned by V.T.I.C. Article 3.50-7.  V.T.I.C. Article 3.50-7 was codified in 2003 as Chapter 1579 of this code.  Because Article 3.50-7A is revised as part of Chapter 1579 and because Chapter 1579 applies only to the program established under former Article 3.50-7, the revised law omits the reference to applicability as unnecessary.  Section 1579.002 of this code, formerly Section 2, V.T.I.C. Article 3.50-7, defines various terms for the purposes of all provisions revised in Chapter 1579.  Those definitions apply to the provisions of V.T.I.C. Article 3.50-7A revised in this section.  Therefore, the revised law omits Section (a), V.T.I.C. Article 3.50-7A, as unnecessary.  The omitted law reads:

Art. 3.50-7A.  (a)  This article applies only to the uniform group coverage program established under Article 3.50-7 of this code.  A term used in this article has the meaning assigned by Section 2, Article 3.50-7, of this code.

(2)  Section (b), V.T.I.C. Article 3.50-7A, as added by Chapter 201, Acts of the 78th Legislature, Regular Session, 2003, refers to an agreement to provide medical and health care services subject to certain "terms and conditions."  The revised law omits "conditions" because "conditions" is included within the meaning of "terms."