The bill, S.B. No. 1287, amends Section 1369.0542 of the Texas Insurance Code to clarify the application of reductions in out-of-pocket expenses for prescription drugs that are considered essential health benefits. It specifies that these reductions must be applied to the enrollee's deductible, copayment, cost-sharing responsibility, or out-of-pocket maximum, regardless of how the health benefit plan issuer, pharmacy benefit manager, or subcontractor classifies the drug. The bill introduces new definitions and responsibilities for health benefit plan issuers and their subcontractors regarding the handling of these reductions.

Additionally, the bill establishes that the amended provisions will only apply to health benefit plans that are delivered, issued for delivery, or renewed on or after January 1, 2026. Plans that are delivered or renewed before this date will continue to be governed by the existing law prior to the amendments. The effective date for this act is set for September 1, 2025.

Statutes affected:
Introduced: Insurance Code 1369.0542 (Insurance Code 1369)