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A BILL TO BE ENTITLED
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AN ACT
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relating to the regulation of pharmacy benefit managers and health |
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benefit plan issuers in relation to prescription drug coverage. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Chapter 1369, Insurance Code, is amended by |
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adding Subchaper A-1 to read as follows: |
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SUBCHAPTER A-1. COMPLAINTS |
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Sec. 1369.021. COMPLAINTS AGAINST PHARMACY BENEFIT |
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MANAGERS. (a) The commissioner may receive and review written |
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complaints alleging violations of this chapter by a pharmacy |
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benefit manager. |
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(b) Based on review under Subsection (a), if the |
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commissioner has reason to believe that a pharmacy benefit manager |
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engaged in a course of conduct exhibited through a pattern or |
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practice that violates this chapter or constitutes improper, |
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fraudulent, or dishonest contract performance with the pharmacist |
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or pharmacy, the commissioner may conduct any investigation |
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necessary to determine whether the pattern or practice exists. |
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(c) The commissioner shall take appropriate disciplinary |
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action as provided by this code against the pharmacy benefit |
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manager if the commissioner finds, based on an investigation |
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authorized by Subsection (b), that the pharmacy benefit manager |
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engaged in a course of conduct exhibited through a pattern or |
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practice that violates this chapter or constitutes improper, |
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fraudulent, or dishonest contract performance with the pharmacist |
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or pharmacy. |
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(d) The commissioner may exercise the subpoena authority |
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under Section 36.152 in an investigation under this section. |
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SECTION 2. Chapter 1369, Insurance Code, is amended by |
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adding Subchapter I to read as follows: |
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SUBCHAPTER I. RELATIONSHIP TO PHARMACISTS AND PHARMACIES |
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Sec. 1369.551. DEFINITIONS. In this subchapter: |
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(1) "Affiliated pharmacist of pharmacy" means a |
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pharmacist or pharmacy that directly, or indirectly through one or |
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more intermediaries, controls or is controlled by, or is under |
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common control with, a pharmacy benefit manager. |
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(2) "Pharmacy benefit manager" means a person, other |
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than a pharmacist or pharmacy, who acts as an administrator in |
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connection with pharmacy benefits. |
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Sec. 1369.552. APPLICABILITY OF SUBCHAPTER. (a) This |
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subchapter applies only to a health benefit plan that provides |
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benefits for medical or surgical expenses incurred as a result of a |
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health condition, accident, or sickness, including an individual, |
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group, blanket, or franchise insurance policy or insurance |
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agreement, a group hospital service contract, or an individual or |
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group evidence of coverage or similar coverage document that is |
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offered by: |
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(1) an insurance company; |
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(2) a group hospital service corporation operating |
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under Chapter 842; |
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(3) a health maintenance organization operating under |
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Chapter 843; |
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(4) an approved nonprofit health corporation that |
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holds a certificate of authority under Chapter 844; |
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(5) a multiple employer welfare arrangement that holds |
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a certificate of authority under Chapter 846; |
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(6) a stipulated premium company operating under |
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Chapter 884; |
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(7) a fraternal benefit society operating under |
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Chapter 885; |
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(8) a Lloyd's plan operating under Chapter 941; or |
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(9) an exchange operating under Chapter 942. |
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(b) Notwithstanding any other law, this subchapter applies |
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to: |
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(1) a small employer health benefit plan subject to |
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Chapter 1501, including coverage provided through a health group |
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cooperative under Subchapter B of that chapter; |
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(2) a standard health benefit plan issued under |
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Chapter 1507; |
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(3) health benefits provided by or through a church |
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benefits board under Subchapter I, Chapter 22, Business |
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Organizations Code; |
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(4) group health coverage made available by a school |
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district in accordance with Section 22.004, Education Code; |
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(5) a regional or local health care program operated |
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under Section 75.104, Health and Safety Code; and |
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(6) a self-funded health benefit plan sponsored by a |
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professional employer organization under Chapter 91, Labor Code. |
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(c) This subchapter does not apply to an issuer or provider |
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of health benefits under or a pharmacy benefit manager |
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administering pharmacy benefits under a workers' compensation |
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insurance policy or other form of providing medical benefits under |
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Title 5, Labor Code. |
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Sec. 1369.553. REDUCTION OF CERTAIN CLAIM PAYMENT AMOUNTS |
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PROHIBITED. (a) A health benefit plan issuer or pharmacy benefit |
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manager may not directly or indirectly reduce the amount of a claim |
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payment to a pharmacist or pharmacy after adjudication of the claim |
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through the use of an aggregated effective rate, a quality |
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assurance program, other direct or indirect remuneration fee, or |
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otherwise, except in accordance with an audit performed under |
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Subchapter F. |
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(b) Nothing in this section prohibits a health benefit plan |
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issuer or pharmacy benefit manager from increasing a claim payment |
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amount after adjudication of the claim. |
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(c) Notwithstanding any other law, this section applies to |
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the Medicaid managed care program operated under Chapter 533, |
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Government Code. |
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Sec. 1369.554. PROFESSIONAL STANDARDS AND SCOPE OF PRACTICE |
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REQUIREMENTS. A health benefit plan issuer or pharmacy benefit |
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manager may not as a condition of a contract with a pharmacist or |
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pharmacy: |
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(1) require pharmacist or pharmacy accreditation |
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standards or recertification requirements inconsistent with, more |
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stringent than, or in addition to federal and state requirements; |
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or |
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(2) prohibit a licensed pharmacist or pharmacy from |
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dispensing any drug, including a specialty drug, that may be |
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dispensed under the pharmacist's or pharmacy's license unless |
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applicable state or federal law prohibits the pharmacist or |
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pharmacy from dispensing the drug. |
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Sec. 1369.555. RESTRICTIONS ON MAIL ORDER PHARMACY |
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SERVICES. A pharmacy benefit manager may not require an enrollee to |
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use a mail order pharmacy. |
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Sec. 1369.556. DELIVERY OF DRUGS. Except in a case in which |
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the health benefit plan issuer or pharmacy benefit manager makes a |
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credible allegation of fraud against the pharmacist or pharmacy and |
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provides reasonable notice of the allegation and the basis of the |
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allegation to the pharmacist or pharmacy, a health benefit plan |
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issuer or pharmacy benefit manager may not as a condition of a |
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contract with a pharmacist or pharmacy prohibit the pharmacist or |
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pharmacy from: |
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(1) mailing or delivering a drug to a patient on the |
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patient's request, to the extent permitted by law; or |
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(2) charging a shipping and handling fee to a patient |
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requesting a prescription be mailed or delivered if the pharmacist |
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or pharmacy discloses to the patient before the delivery: |
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(A) the fee that will be charged; and |
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(B) that the fee may not be reimbursable by the |
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health benefit plan issuer or pharmacy benefit manager. |
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Sec. 1369.557. PROHIBITION ON CERTAIN REFERRALS. (a) A |
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health benefit plan issuer or pharmacy benefit manager may not |
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steer or direct a patient to use an affiliated pharmacist or |
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pharmacy through: |
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(1) any oral or written communication, including: |
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(A) online messaging regarding the pharmacist or |
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pharmacy; or |
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(B) patient- or prospective patient-specific |
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advertising, marketing, or promotion of the pharmacist or pharmacy; |
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or |
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(2) offering or implementing a health benefit plan |
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design that requires or induces a patient to use an affiliated |
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pharmacist or pharmacy, including by providing for reduced |
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cost-sharing amounts if the patient uses the pharmacist or |
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pharmacy. |
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(b) This section does not prohibit a health benefit plan |
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issuer or pharmacy benefit manager from including an affiliated |
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pharmacist or pharmacy in the issuer's or manager's patient |
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communications, including in a patient- or prospective |
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patient-specific communication, if the communication: |
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(1) is regarding in-network pharmacies and prices for |
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a health benefit plan; |
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(2) is accurate; and |
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(3) includes in-network pharmacists or pharmacies |
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that are not affiliated pharmacists or pharmacies. |
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(c) An affiliated pharmacist or pharmacy may not present a |
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claim for payment to any individual or entity, including to a |
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third-party payor, health benefit plan, or pharmacy benefit |
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manager, for a health care service or supply provided to a patient |
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who was improperly steered or directed to use the affiliated |
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pharmacist or pharmacy in violation of Subsection (a). |
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Sec. 1369.558. PROHIBITION ON SHARING PATIENT INFORMATION |
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FOR CERTAIN PURPOSES. (a) In this section, "commercial purpose" |
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does not include pharmacy reimbursement, formulary compliance, |
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pharmaceutical care, utilization review by a health care provider, |
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or a public health activity authorized by law. |
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(b) A health benefit plan issuer or pharmacy benefit manager |
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may not transfer to or receive from an affiliated pharmacist or |
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pharmacy a record containing patient- or prescriber-identifiable |
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prescription information for a commercial purpose. |
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SECTION 3. The change in law made by this Act applies only |
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to a contract entered into or renewed on or after the effective date |
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of this Act. A contract entered into or renewed before the |
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effective date of this Act is governed by the law as it existed |
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immediately before the effective date of this Act, and that law is |
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continued in effect for that purpose. |
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SECTION 4. This Act takes effect September 1, 2021. |