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A BILL TO BE ENTITLED
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AN ACT
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relating to the delivery of prescription drugs for certain state |
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health plans by mail order; providing an administrative penalty. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle H, Title 8, Insurance Code, is amended |
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by adding Chapter 1560 to read as follows: |
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CHAPTER 1560. DELIVERY OF PRESCRIPTION DRUGS BY MAIL |
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Sec. 1560.001. DEFINITIONS. In this chapter: |
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(1) "Community retail pharmacy" means a pharmacy that |
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is licensed as a Class A pharmacy under Chapter 560, Occupations |
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Code. |
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(2) "Mail order pharmacy" means a pharmacy that is |
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licensed under Chapter 560, Occupations Code, and that primarily |
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delivers prescription drugs to an enrollee through the United |
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States Postal Service or a commercial delivery service. |
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(3) "Prescription drug formulary" means a list of |
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prescription drugs preferred for use and eligible for coverage |
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under a health benefit plan. |
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Sec. 1560.002. APPLICABILITY OF CHAPTER. This chapter |
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applies only to a health benefit plan that provides benefits for |
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medical or surgical expenses incurred as a result of a health |
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condition, accident, or sickness, including an individual, group, |
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blanket, or franchise insurance policy or insurance agreement, a |
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group hospital service contract, or an individual or group evidence |
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of coverage or similar coverage document that is offered or |
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administered by: |
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(1) the Teacher Retirement System of Texas under |
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Chapter 1575 or 1579; or |
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(2) the Employees Retirement System of Texas under |
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Chapter 1551. |
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Sec. 1560.003. ACCESS TO PHARMACIES. (a) Notwithstanding |
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any other law, an issuer of a health benefit plan that provides |
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pharmacy benefits to enrollees may not: |
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(1) require an enrollee, as a condition of obtaining |
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benefits or reimbursement for prescription drugs or pharmacy |
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services, to obtain the drugs or services exclusively from a mail |
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order pharmacy; |
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(2) discriminate between different pharmacies based |
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on whether the pharmacy is a mail order pharmacy or a community |
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retail pharmacy by: |
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(A) limiting the quantity of a prescription drug |
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an enrollee may obtain from the pharmacy, including limiting the |
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number of days of supply or number of units of a prescription drug |
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or the number of prescriptions or refills of a prescription drug the |
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enrollee may obtain; |
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(B) requiring an enrollee to pay a different |
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copayment, coinsurance, or deductible amount; or |
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(C) using different prescription drug |
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formularies for mail order pharmacies and community retail |
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pharmacies; |
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(3) provide a monetary incentive or impose a monetary |
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penalty on an enrollee that could reasonably be expected to affect |
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the enrollee's choice among pharmacies that have agreed to |
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participate in the health benefit plan; or |
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(4) prohibit a pharmacy licensed under Chapter 560, |
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Occupations Code, from participating under the health benefit plan |
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if the pharmacy meets all of the conditions of and agrees to all of |
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the terms of participation in the health benefit plan. |
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(b) An issuer of a health benefit plan that provides |
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pharmacy benefits to enrollees shall offer all pharmacies the same |
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conditions and terms of participation in the health benefit plan, |
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including prescription drug reimbursement rates, regardless of |
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whether a pharmacy is a mail order pharmacy or a community retail |
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pharmacy. |
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Sec. 1560.004. PRESCRIPTION DRUG REIMBURSEMENT RATES. (a) |
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An issuer of a health benefit plan that provides pharmacy benefits |
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to enrollees shall reimburse pharmacies participating in the health |
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plan using prescription drug reimbursement rates that are based on |
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a current and nationally recognized benchmark index for both brand |
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name and generic prescription drugs. |
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(b) An issuer of a health benefit plan shall use the same |
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benchmark index, including the same national prescription drug |
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codes, to reimburse all pharmacies participating in the health |
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benefit plan, regardless of whether the pharmacy is a mail order |
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pharmacy or a community retail pharmacy. |
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Sec. 1560.005. ACQUISITION COSTS AND REBATES. (a) An |
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issuer of a health benefit plan that contracts with a third-party |
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administrator, pharmacy benefit manager, or other entity to manage |
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pharmacy benefits provided to enrollees through a mail order |
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pharmacy shall require the managing entity to: |
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(1) provide the issuer of the health benefit plan with |
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an annual electronic report containing: |
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(A) the actual acquisition cost of all drugs |
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purchased by the managing entity in relation to the pharmacy |
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benefits under the health benefit plan; and |
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(B) an identification of the source, type, and |
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amount of all rebates, rebate administrative fees, and other |
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monetary benefits received by the managing entity from a drug |
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manufacturer in relation to the pharmacy benefits under the health |
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benefit plan; and |
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(2) not later than the 30th day after the date the |
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managing entity receives a rebate, rebate administrative fee, or |
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other monetary benefit from a drug manufacturer in relation to the |
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pharmacy benefits under the health benefit plan, reimburse or |
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credit to the issuer of the health benefit plan an amount equal to |
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the amount of the rebate, rebate administrative fee, or other |
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monetary benefit received by the managing entity. |
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Sec. 1560.006. PHARMACY BENEFIT MANAGERS: DESIGNATION OF |
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CONFIDENTIAL INFORMATION (a) A pharmacy benefit manager may |
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designate as confidential any information the pharmacy benefit |
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manager is required to disclose under Section 1560.005. |
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(b) Information designated as confidential under this |
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section may not be disclosed to any person without the consent of |
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the pharmacy benefit manager unless the disclosure is: |
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(1) ordered by a court for good cause shown; |
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(2) made under seal in a court filing; or |
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(3) made to the commissioner of insurance or the attorney |
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general in connection with an investigation authorized by this |
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code, the Government Code, or any other law. |
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Sec. 1560.007. COMPLAINT AND ENFORCEMENT; ADMINISTRATIVE |
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PENALTIES. (a) The department shall investigate any complaint |
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that the department receives concerning conduct regulated by this |
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chapter. |
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(b) Following an investigation under Subsection (a), the |
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commissioner shall issue a written determination of the outcome of |
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the investigation, including whether the department has taken or |
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intends to take any action under Chapters 81-86. |
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(c) If, as a result of a complaint investigated under |
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Subsection (a), the commissioner determines that an issuer of a |
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health benefit plan has violated this chapter, the commissioner |
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shall impose an administrative penalty against the issuer of the |
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health benefit plan in accordance with Chapter 84. The amount of an |
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administrative penalty imposed under this subsection may not exceed |
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$1,000 per prescription that was filled or that was not filled in |
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violation of this chapter. The limitation on the amount of an |
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administrative penalty under Section 84.022 does not apply to an |
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administrative penalty imposed under this subsection. |
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SECTION 2. Section 1551.219, Insurance Code, as added by |
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Chapter 213, Acts of the 78th Legislature, Regular Session, 2003, |
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is amended to read as follows: |
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Sec. 1551.219. MAIL ORDER REQUIREMENT FOR PRESCRIPTION DRUG |
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COVERAGE PROHIBITED. The board of trustees or a health benefit plan |
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under this chapter that provides benefits for prescription drugs |
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may not require a participant in the group benefits program to |
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purchase a prescription drug through a mail order program. The |
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board or health benefit plan may not [shall] require that a |
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participant who chooses to obtain a prescription drug through a |
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retail pharmacy or other method other than by mail order pay a |
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deductible, copayment, coinsurance, or other cost-sharing |
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obligation to cover the additional cost of obtaining a prescription |
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drug through that method rather than by mail order. |
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SECTION 3. The change in law made this Act applies only to a |
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health benefit plan that is delivered, issued for delivery, or |
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renewed on or after January 1, 2008. A health benefit plan that is |
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delivered, issued for delivery, or renewed before January 1, 2008, |
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is covered by the law in effect at the time the policy was |
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delivered, issued for delivery, or renewed, 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, 2007. |