A health benefit plan issuer may not impose certain pharmacy-network restrictions or extra charges for clinician-administered drugs for covered enrollees with specified serious medical conditions, subject to medical-risk findings by the patient’s physician or health care provider.
Sec. 1369.764. CERTAIN LIMITATIONS ON COVERAGE OF CLINICIAN-ADMINISTERED DRUGS PROHIBITED. (a) Subject to Subsection (b), a health benefit plan issuer may not, for an enrollee with a chronic, complex, rare, or life-threatening medical condition: (1) require clinician-administered drugs to be dispensed only by certain pharmacies or only by pharmacies participating in the health benefit plan issuer's network; (2) if a clinician-administered drug is otherwise covered, limit or exclude coverage for such drugs based on the enrollee's choice of pharmacy or because the drug was not dispensed by a pharmacy that participates in the health benefit plan issuer's network; (3) require a physician or health care provider participating in the health benefit plan issuer's network to bill for or be reimbursed for the delivery and administration of clinician-administered drugs under the pharmacy benefit instead of the medical benefit without: (A) informed written consent of the patient; and (B) a written attestation by the patient's physician or health care provider that a delay in the drug's administration will not place the patient at an increased health risk; or (4) require that an enrollee pay an additional fee, higher copay, higher coinsurance, second copay, second coinsurance, or any other price increase for clinician-administered drugs based on the enrollee's choice of pharmacy or because the drug was not dispensed by a pharmacy that participates in the health benefit plan issuer's network. (b) Subsection (a) applies only if the patient's physician or health care provider determines that: (1) a delay of care would make disease progression probable; or (2) the use of a pharmacy within the health benefit plan issuer's network would: (A) make death or patient harm probable; (B) potentially cause a barrier to the patient's adherence to or compliance with the patient's plan of care; or (C) because of the timeliness of the delivery or dosage requirements, necessitate delivery by a different pharmacy. (c) Nothing in this section may be construed to: (1) authorize a person to administer a drug when otherwise prohibited under the laws of this state or federal law; or (2) modify drug administration requirements under the laws of this state, including any requirements related to delegation and supervision of drug administration. Added by Acts 2023, 88th Leg., R.S., Ch. 417 (H.B. 1647), Sec. 1, eff. September 1, 2023.