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A BILL TO BE ENTITLED
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AN ACT
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relating to the relationship between pharmacists or pharmacies and |
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pharmacy benefit managers or health benefit plan issuers. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subchapter D, Chapter 4151, Insurance Code, is |
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amended by adding Section 4151.155 to read as follows: |
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Sec. 4151.155. REDUCTION OF CERTAIN CLAIM PAYMENT AMOUNTS |
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PROHIBITED. (a) A pharmacy benefit manager may not directly or |
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indirectly reduce the amount of a claim payment to a pharmacist or |
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pharmacy after adjudication of the claim through the use of an |
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aggregated effective rate, a quality assurance program, other |
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direct or indirect remuneration fee, or otherwise, except in |
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accordance with an audit. |
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(b) Nothing in this section prohibits a pharmacy benefit |
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manager from increasing a claim payment amount after adjudication |
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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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SECTION 2. Chapter 562, Occupations Code, is amended by |
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adding Subchapter E to read as follows: |
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SUBCHAPTER E. CONTRACTS WITH PHARMACISTS AND PHARMACIES |
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Sec. 562.201. DEFINITION. In this subchapter, "pharmacy |
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benefit manager" has the meaning assigned by Section 4151.151, |
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Insurance Code. |
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Sec. 562.202. 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, Insurance Code; |
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(3) a health maintenance organization operating under |
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Chapter 843, Insurance Code; |
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(4) an approved nonprofit health corporation that |
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holds a certificate of authority under Chapter 844, Insurance Code; |
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(5) a multiple employer welfare arrangement that holds |
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a certificate of authority under Chapter 846, Insurance Code; |
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(6) a stipulated premium company operating under |
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Chapter 884, Insurance Code; |
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(7) a fraternal benefit society operating under |
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Chapter 885, Insurance Code; |
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(8) a Lloyd's plan operating under Chapter 941, |
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Insurance Code; or |
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(9) an exchange operating under Chapter 942, Insurance |
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Code. |
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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, Insurance Code, including coverage provided through a |
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health group 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, Insurance Code; |
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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) 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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(5) 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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Sec. 562.203. 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. 562.204. RESTRICTIONS ON MAIL ORDER PHARMACY SERVICES. |
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A pharmacy benefit manager may not require an enrollee to use a mail |
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order pharmacy. |
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Sec. 562.205. 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. 562.206. WAIVER PROHIBITED. The provisions of this |
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subchapter may not be waived, voided, or nullified by contract. |
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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. |
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* * * * * |