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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; providing |
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administrative and criminal penalties. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle D, Title 13, Insurance Code, is amended |
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by adding Chapter 4154 to read as follows: |
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CHAPTER 4154. PHARMACY BENEFIT MANAGERS |
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SUBCHAPTER A. GENERAL PROVISIONS |
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Sec. 4154.001. DEFINITIONS. In this chapter: |
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(1) "Board" means the Texas State Board of Pharmacy. |
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(2) "Claims processing service" means an |
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administrative service performed in connection with the processing |
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and adjudication of a claim relating to pharmaceutical services, |
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including making payments to pharmacists and pharmacies. |
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(3) "Common controlling interest" means that a |
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controlling interest in two persons is held by the same person. |
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(4) "Controlling interest" means that a person |
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directly or indirectly owns, controls, holds with the power to |
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vote, or holds proxies representing 50 percent or more of the voting |
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interests of another person. |
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(5) "Labor union" has the meaning assigned by Section |
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101.051, Labor Code. |
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(6) "Maintenance drug" means a drug: |
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(A) prescribed by a health care practitioner who |
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is licensed to prescribe drugs; and |
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(B) used to treat a medical condition for a |
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period greater than 30 days. |
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(7) "Multi-source drug" means a drug that is stocked |
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and available from at least three suppliers. |
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(8) "Other prescription drug or device service" means |
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a service, other than a claims processing service, that is provided |
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directly or indirectly by a pharmacy benefit manager, whether in |
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connection with or separate from claims processing services, |
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including: |
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(A) negotiating a rebate, discount, other |
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financial incentive, or other arrangement with a drug company; |
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(B) disbursing or distributing a rebate; |
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(C) managing or participating in an incentive |
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program or arrangement for the services of a pharmacist; |
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(D) negotiating or entering into a contractual |
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arrangement with a pharmacist, a pharmacy, or both; |
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(E) developing drug formularies; and |
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(F) advertising or promoting claims processing |
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services or other prescription drug or device services. |
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(9) "Person" means an individual, corporation, |
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organization, trust, partnership, or other legal entity. |
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(10) "Pharmacist" has the meaning assigned by Section |
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551.003(28), Occupations Code. |
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(11) "Pharmacist's service" means a service that is |
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provided by a pharmacist, including drug therapy or another patient |
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care service, as defined by board rules, that is intended to achieve |
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outcomes related to: |
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(A) curing or preventing a disease; |
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(B) eliminating or reducing a patient's |
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symptoms; or |
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(C) arresting or slowing a disease process. |
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(12) "Pharmacy" has the meaning assigned by Section |
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551.003(31), Occupations Code. |
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(13) "Pharmacy benefit manager" means a person and any |
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wholly or partially owned or controlled subsidiary of the person, |
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that provides to third parties claims processing services, other |
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prescription drug or device services, or both services. The term |
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does not include: |
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(A) a health care facility licensed in this |
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state; |
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(B) a health care practitioner licensed in this |
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state; |
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(C) a pharmacy licensed in this state; |
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(D) an insurer authorized to engage in the |
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business of insurance in this state; |
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(E) a health maintenance organization that holds |
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a certificate of authority under Chapter 843; |
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(F) a labor union; or |
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(G) a consultant who only provides advice as to |
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the selection or performance of a pharmacy benefit manager. |
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(14) "Single source drug" means a drug other than a |
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multi-source drug. |
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(15) "Third party" means any person who is not a |
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pharmacy benefit manager. The term does not include: |
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(A) a person that holds a controlling interest in |
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a pharmacy benefit manager; |
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(B) a person that shares a common controlling |
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interest with a pharmacy benefit manager; or |
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(C) a policyholder, insured, member, or enrollee |
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of an insurer authorized to engage in the business of insurance in |
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this state or a health maintenance organization that holds a |
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certificate of authority under Chapter 843, to the extent that |
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claims processing services, other prescription drug or device |
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services, or both services, are provided to the policyholder, |
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insured, member, or enrollee by a person: |
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(i) in which the insurance company or |
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health maintenance organization holds a controlling interest; or |
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(ii) that shares common controlling |
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interest with the insurer or health maintenance organization. |
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(16) "Usual and customary price" means the price that |
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a pharmacist or pharmacy would charge a patient paying cash for the |
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same services provided on the same date to another patient, other |
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than a patient whose reimbursement rates are set by contract. |
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Sec. 4154.002. RULES. The commissioner shall adopt rules |
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and standards as necessary to implement this chapter. |
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Sec. 4154.003. APPLICABILITY OF OTHER PROVISIONS OF CODE. |
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A pharmacy benefit manager is subject to Section 823.457, |
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Subchapter H of Chapter 101, Chapter 541, Subchapter A of Chapter |
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542, and Chapter 804. |
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Sec. 4154.004. PHARMACY BENEFIT MANAGER NOT INSURANCE |
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AGENT. (a) A pharmacy benefit manager licensed in any state who |
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accepts an agent's commission for coverage for a risk located in |
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this state and disburses that commission to an agent in this state |
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is not considered an agent for purposes of this title. |
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(b) The exemption provided by this section does not |
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authorize a pharmacy benefit manager to perform any other act for |
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which a license as an agent is required by law. |
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[Sections 4154.005-4154.050 reserved for expansion] |
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SUBCHAPTER B. CERTIFICATE OF AUTHORITY; LICENSE |
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Sec. 4154.051. CERTIFICATE OF AUTHORITY REQUIRED; BOARD |
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LICENSE REQUIRED. (a) A person may not act as or represent that the |
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person is a pharmacy benefit manager in this state unless the person |
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is covered by and is engaging in business under a certificate of |
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authority issued by the commissioner under this chapter. |
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(b) In addition to the certificate of authority issued by |
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the commissioner, a person may not act as or represent that the |
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person is a pharmacy benefit manager in this state unless the person |
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holds a pharmacy benefit manager license issued by the board under |
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Chapter 570, Occupations Code. |
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(c) A person that holds a certificate of authority under |
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this chapter is not also required to hold a certificate of authority |
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as an administrator under Chapter 4151 to act as a pharmacy benefit |
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manager in this state. |
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Sec. 4154.052. APPLICATION REQUIREMENTS. (a) An applicant |
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for a certificate of authority under this chapter shall submit an |
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application to the department in the manner prescribed by the |
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commissioner. |
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(b) An application under this chapter must: |
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(1) include the information required in an application |
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made under Section 4151.052 and other information as required by |
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the commissioner; and |
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(2) be accompanied by a $300 application fee. |
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Sec. 4154.053. FIDELITY BOND REQUIRED. (a) If the |
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commissioner approves an application under Section 4154.052 for a |
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certificate of authority, before the commissioner issues the |
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certificate of authority, the applicant must: |
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(1) obtain and maintain a fidelity bond that complies |
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with this section; and |
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(2) submit to the commissioner proof that the |
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applicant has obtained the fidelity bond. |
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(b) The fidelity bond must protect against an act of fraud |
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or dishonesty by the applicant in exercising the applicant's powers |
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and duties as a pharmacy benefit manager. |
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(c) The fidelity bond must be equal to at least 10 percent of |
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the amount of money handled by the pharmacy benefit manager during |
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the preceding year or, if no money was handled during the preceding |
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year, 10 percent of the amount of money reasonably estimated to be |
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handled by the pharmacy benefit manager during the calendar year in |
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which the license is issued. |
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(d) For purposes of this section, the amount of money |
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handled by a person in the person's capacity as pharmacy benefit |
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manager is the greater of the total amount of premiums and |
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contributions received by the pharmacy benefit manager or the total |
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amount of benefits paid by the pharmacy benefit manager in all |
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jurisdictions in which the person acts as a pharmacy benefit |
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manager. |
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(e) Unless the pharmacy benefit manager and an insurer, |
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health maintenance organization, or benefit plan sponsor agree |
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otherwise in writing, a pharmacy benefit manager is required to |
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obtain and maintain only one fidelity bond for all of the pharmacy |
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benefit manager's activities as a pharmacy benefit manager in this |
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state. |
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Sec. 4154.054. ISSUANCE OF CERTIFICATE; DURATION OF |
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CERTIFICATE; RENEWAL. (a) The commissioner shall issue a |
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certificate of authority to an applicant that complies with this |
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chapter. |
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(b) A pharmacy benefit manager is required to hold only one |
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certificate of authority issued under this chapter. |
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(c) A certificate of authority issued under this chapter is |
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valid for two years from the date of issuance, and may be renewed on |
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submission of a renewal application to the department accompanied |
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by a $300 renewal fee. |
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[Sections 4154.055-4154.100 reserved for expansion] |
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SUBCHAPTER C. DEPARTMENT REGULATION OF PHARMACY BENEFIT MANAGERS |
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Sec. 4154.101. EXAMINATION OF PHARMACY BENEFIT MANAGER. |
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(a) The commissioner may examine a pharmacy benefit manager with |
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regard to the manager's business in this state. |
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(b) An examination under this section must include a review |
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of: |
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(1) each existing written agreement between the |
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pharmacy benefit manager and an insurer, health maintenance |
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organization, or benefit plan sponsor; and |
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(2) the pharmacy benefit manager's financial |
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statements. |
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(c) The commissioner may also require an on-site evaluation |
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of the pharmacy benefit manager's personnel and facilities and any |
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books and records of the pharmacy benefit manager relating to the |
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transaction of business by and the financial condition of the |
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pharmacy benefit manager. Before an examiner enters the property |
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of the pharmacy benefit manager, the examiner must notify the |
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pharmacy benefit manager of the date and estimated time of the |
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examination in the manner prescribed by commissioner rule. The |
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examiner shall comply with any operational rules of the pharmacy |
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benefit manager while on the pharmacy benefit manager's property. |
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(d) The pharmacy benefit manager shall pay a fee to the |
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department not to exceed $500 to cover the costs of an examination |
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under this section. |
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Sec. 4154.102. ANNUAL STATEMENT. (a) Not later than March |
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1 of each year, each pharmacy benefit manager shall file with the |
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department an annual statement for the preceding calendar year. |
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(b) The annual statement must be made on a form and in the |
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manner prescribed by the commissioner, accompanied by a $1,000 |
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filing fee, and must include the number and value of claims for |
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pharmacists' services that are processed by the pharmacy benefit |
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manager for the preceding calendar year for all patients who are |
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residents of this state. |
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Sec. 4154.103. EXTENSION OF FILING PERIOD. The |
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commissioner may extend, for a period not to exceed 60 days, the |
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time prescribed for the filing of an annual statement or other |
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report or exhibit by a pharmacy benefit manager for good cause. |
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Sec. 4154.104. ASSESSMENT. (a) In addition to the fees |
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required under this chapter, the commissioner shall annually assess |
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each pharmacy benefit manager holding a certificate of authority |
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under this chapter for the department's expenses in administering |
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this chapter. |
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(b) The commissioner shall proportionately assess each |
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pharmacy benefit manager under Subsection (a) for its share of the |
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total expenses incurred by the department in administering this |
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chapter in proportion to the business done by all pharmacy benefit |
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managers in this state, as determined by the commissioner by rule. |
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Sec. 4154.105. CHANGE IN OWNERSHIP. A pharmacy benefit |
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manager must notify the department in writing of any material |
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change in the ownership of the pharmacy benefit manager not later |
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than the fifth day after the effective date of the change of |
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ownership. |
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Sec. 4154.106. ARBITRATION. (a) The commissioner by rule |
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shall establish a procedure that uses arbitration for resolving |
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disputes arising under contracts entered into by pharmacy benefit |
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managers. |
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(b) The arbitration procedure adopted under Subsection (a) |
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must include participation by: |
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(1) pharmacy benefit managers or their |
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representatives; |
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(2) insurers, health maintenance organizations, or |
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benefit plan sponsors; and |
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(3) pharmacists. |
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[Sections 4154.107-4154.150 reserved for expansion] |
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SUBCHAPTER D. CONTRACT ISSUES |
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Sec. 4154.151. STANDARD CONTRACT FORMS REQUIRED. (a) The |
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commissioner, in consultation with the contract advisory panel |
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established under Section 4154.152, shall adopt rules that |
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establish standard contract forms for use by pharmacy benefit |
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managers in entering into contracts with pharmacies and pharmacists |
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and insurers, health maintenance organizations, and benefit plan |
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sponsors. |
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(b) Except as provided by Section 4154.153, a pharmacy |
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benefit manager that enters into a contract with a pharmacy or |
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pharmacist or insurer, health maintenance organization, or benefit |
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plan sponsor must use a contract form adopted by the commissioner |
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under this section. |
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(c) The terms of a contract form adopted under this section |
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and entered into by a pharmacy benefit manager and a pharmacy or |
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pharmacist or insurer, health maintenance organization, or benefit |
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plan sponsor may not be subsequently modified unless the |
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modification is agreed to by the pharmacy benefit manager and the |
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pharmacy or the pharmacist or the insurer, health maintenance |
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organization, or benefit plan sponsor. |
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Sec. 4154.152. PHARMACY BENEFIT MANAGER CONTRACT ADVISORY |
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PANEL. (a) The pharmacy benefit manager contract advisory panel is |
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established as an advisory body to the commissioner. The advisory |
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panel shall advise and make recommendations to the commissioner |
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regarding the adoption of standard contract forms under Section |
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4154.151. |
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(b) The advisory panel is composed of nine members appointed |
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jointly by the commissioner and the board as follows: |
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(1) two members must be attorneys who primarily |
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represent insurers, health maintenance organizations, or benefit |
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plan sponsors; |
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(2) two members must be pharmacists; |
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(3) two members must be pharmacy benefit managers who |
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hold certificates of authority under this chapter; and |
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(4) three members must be public members. |
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(c) A public member of the advisory panel may not: |
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(1) receive any compensation from, or be employed |
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directly or indirectly by, a pharmacist, pharmacy benefit manager, |
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health care provider, insurer, health maintenance organization, or |
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benefit plan sponsor; |
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(2) be a pharmacist or pharmacy benefit manager; or |
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(3) be a person required to register as a lobbyist |
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under Chapter 305, Government Code, because of the person's |
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activities for compensation on behalf of a profession related to |
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the operation of the advisory panel. |
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(d) Members of the advisory panel serve without |
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compensation and at the will of the commissioner. |
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(e) Section 2110.008, Government Code, does not apply to the |
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advisory panel. |
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Sec. 4154.153. COMMISSIONER APPROVAL OF CONTRACT FORMS. |
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(a) Not later than the 30th day before the date on which a pharmacy |
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benefit manager proposes to use a form in this state, other than a |
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form adopted under Section 4154.151, for a contract entered into |
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with a pharmacy or pharmacist to provide services in this state, the |
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pharmacy benefit manager must file the form with the department. |
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(b) Each contract form is subject to approval by the |
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commissioner. If the commissioner fails to approve a form before |
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the 31st day after the date on which the form is received by the |
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department, the form is deemed disapproved. |
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(c) The commissioner by rule shall develop formal criteria |
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for the approval and disapproval of pharmacy benefit manager |
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contract forms under this section. |
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Sec. 4154.154. CONTRACT TERMS. (a) Each contract entered |
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into by a pharmacy benefit manager under this chapter must: |
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(1) establish specific times within which the pharmacy |
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benefit manager is required to pay a pharmacy, a pharmacist, or both |
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for services rendered; |
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(2) include a provision stating that a pharmacy is not |
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liable for the acts or omissions of the pharmacy benefit manager; |
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and |
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(3) establish the average wholesale price of a |
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prescription drug or device that is used as an index for claim |
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payments. |
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(b) A pharmacy benefit manager contract may not: |
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(1) establish basic recordkeeping requirements for a |
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pharmacy or pharmacist that are more stringent than the |
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recordkeeping requirements required by state or federal laws or |
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rules; |
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(2) require a pharmacy or pharmacist to change a |
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maintenance drug prescribed for a patient unless the prescribing |
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physician orders the change; or |
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(3) limit the services a pharmacist may provide to a |
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range narrower than the scope of the pharmacist's license to |
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practice pharmacy. |
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[Sections 4154.155-4154.200 reserved for expansion] |
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SUBCHAPTER E. POWERS AND DUTIES OF PHARMACY BENEFIT MANAGERS |
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Sec. 4154.201. IDENTIFICATION CARDS. (a) Except as |
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provided by commissioner rules, a pharmacy benefit manager shall |
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issue an identification card to each individual covered by a plan |
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that provides pharmacy benefits. The pharmacy benefit manager |
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shall issue the identification card not later than the 30th day |
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after the date the pharmacy benefit manager receives notice that |
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the individual is eligible for the benefits. |
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(b) The commissioner by rule shall adopt standard |
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information to be included on the identification card. The |
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standard form identification card must include: |
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(1) the name or logo of the entity administering the |
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pharmacy benefits; |
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(2) the international identification number assigned |
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by the American National Standards Institute for the entity |
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administering the pharmacy benefits; |
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(3) the group number applicable to the covered |
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individual; |
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(4) the effective date of the coverage evidenced by |
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the card; |
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(5) a telephone number to be used to contact an |
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appropriate person to obtain information relating to the pharmacy |
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benefits provided under the coverage; and |
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(6) copayment information for generic and brand-name |
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prescription drugs covered by the plan. |
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Sec. 4154.202. DISCLOSURE OF CERTAIN PATIENT INFORMATION |
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PROHIBITED. (a) A pharmacy benefit manager may not sell a list of |
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patients that contains information through which the identity of an |
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individual patient is disclosed. |
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(b) A pharmacy benefit manager shall maintain all data that |
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identifies a patient in a confidential manner that prevents |
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disclosure to a third party unless the disclosure is otherwise |
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authorized by law or by the patient. |
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(c) This section does not prohibit: |
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(1) general advertising about a specific |
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pharmaceutical product or service; or |
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(2) the request and receipt by a person of information |
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regarding: |
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(A) a specific pharmaceutical product or |
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service; |
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(B) the person's own records or claims; or |
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(C) the person's dependent's records or claims. |
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Sec. 4154.203. MEDICATION REIMBURSEMENT COSTS; INDEX. (a) |
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Each pharmacy benefit manager shall use a current nationally |
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recognized benchmark as the basis for reimbursements for |
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medications and products dispensed by pharmacies and pharmacists |
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with whom the pharmacy benefit manager contracts. |
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(b) For brand-name single source drugs and brand-name |
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multi-source drugs, the pharmacy benefit manager shall use as an |
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index the average wholesale price, as listed in: |
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(1) First DataBank; |
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(2) Facts & Comparisons; or |
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(3) a comparable source recognized by the |
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commissioner, as provided by Subsection (d). |
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(c) For generic multi-source drugs, maximum allowable costs |
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shall be established by referencing the baseline price, as listed |
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in: |
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(1) First DataBank; |
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(2) Facts & Comparisons; or |
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(3) a comparable source recognized by the |
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commissioner, as provided by Subsection (d). |
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(d) If a publication specified in Subsection (b) or (c) |
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ceases to be a nationally recognized benchmark for reimbursement |
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for medication and products dispensed by pharmacies and |
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pharmacists, the commissioner may adopt any other current |
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nationally recognized benchmark that is established and published |
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by a person with whom pharmacy benefit managers do not have a |
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financial or business interest or connection. |
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(e) To be eligible to be reimbursed through a maximum |
|
allowable cost price methodology, a product must: |
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(1) be equivalent and generically interchangeable as |
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provided by state laws related to pharmaceutical products; and |
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(2) have a United States Food and Drug Administration |
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Orange Book rating of "A" through "B". |
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(f) If a generic multi-source drug product does not have a |
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baseline price, the drug shall be treated as a brand-name single |
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source drug for the purpose of valuing reimbursement. |
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[Sections 4154.204-4154.250 reserved for expansion] |
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SUBCHAPTER F. PROHIBITED ACTIONS BY PHARMACY BENEFIT MANAGERS |
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Sec. 4154.251. CERTAIN RETROACTIVE CLAIM ADJUSTMENTS |
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PROHIBITED. (a) A pharmacy benefit manager may not retroactively |
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deny a claim paid by the pharmacy benefits manager for a |
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pharmacist's services or adjust the claim after adjudication of the |
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claim unless: |
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(1) the original claim was submitted fraudulently; |
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(2) the payment of the original claim was in error |
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because the pharmacy or pharmacist had already been paid for the |
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pharmacist's services; or |
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(3) the services in question were not rendered by the |
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pharmacy or pharmacist. |
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(b) A pharmacy benefit manager may not retroactively |
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reverse an acknowledgment of eligibility. |
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Sec. 4154.252. DECEPTIVE ADVERTISEMENTS OR OFFERS |
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PROHIBITED. A pharmacy benefit manager, or a representative of a |
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pharmacy benefit manager, may not cause or knowingly permit the use |
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of an advertisement, promotion, solicitation, proposal, or offer |
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that is untrue, deceptive, or misleading. |
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Sec. 4154.253. PROHIBITED ACTIONS AGAINST PHARMACY OR |
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PHARMACIST. A pharmacy benefit manager may not penalize a pharmacy |
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or terminate a contract with a pharmacy solely because the pharmacy |
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or a pharmacist employed by the pharmacy: |
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(1) files a complaint with the department against the |
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pharmacy benefit manager; |
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(2) disagrees with the pharmacy benefit manager's |
|
decision to deny or limit benefits to an insured, member, or |
|
enrollee; |
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(3) assists an insured, member, or enrollee in seeking |
|
reconsideration of the pharmacy benefit manager's decision to deny |
|
or limit benefits to the insured, member, or enrollee; or |
|
(4) discusses alternative prescription drugs or |
|
devices with an insured, member, or enrollee. |
|
[Sections 4154.254-4154.300 reserved for expansion] |
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SUBCHAPTER G. ENFORCEMENT; SANCTIONS |
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Sec. 4154.301. ENFORCEMENT; RULES. The commissioner shall |
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adopt rules as necessary to enforce this chapter. In adopting rules |
|
under this section, the commissioner shall consult and cooperate |
|
with the board as necessary to coordinate enforcement of the |
|
certificate of authority requirements adopted under this chapter |
|
with the license requirements adopted under Chapter 570, |
|
Occupations Code. |
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Sec. 4154.302. COMPLAINTS; INVESTIGATION. (a) The |
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commissioner by rule shall adopt procedures for investigation of |
|
complaints concerning the failure of a pharmacy benefit manager to |
|
comply with this chapter. |
|
(b) The commissioner shall refer a complaint received under |
|
this chapter to the board if the complaint involves: |
|
(1) a pharmacy or a pharmacist or other health care |
|
practitioner regulated under Subtitle J, Title 3, Occupations Code; |
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or |
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(2) an issue regarding patient health or safety. |
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Sec. 4154.303. DISCIPLINARY ACTIONS. If the commissioner |
|
has reason to believe that a violation of this chapter has occurred, |
|
the commissioner may: |
|
(1) issue an emergency cease and desist order under |
|
Chapter 83 against the pharmacy benefit manager; or |
|
(2) impose any other necessary or appropriate sanction |
|
under Chapter 82, including suspension or revocation of the |
|
pharmacy benefit manager's certificate of authority. |
|
Sec. 4154.304. ADMINISTRATIVE PENALTY. A person that acts |
|
as a pharmacy benefit manager without a certificate of authority |
|
issued under this chapter is subject to administrative penalties |
|
under Chapter 84. An administrative penalty imposed under this |
|
section may not be less than $5,000 or greater than $10,000 for each |
|
violation. |
|
Sec. 4154.305. CRIMINAL PENALTY. (a) A pharmacy benefit |
|
manager commits an offense if the pharmacy benefit manager |
|
knowingly violates this chapter or a commissioner rule adopted |
|
under this chapter. |
|
(b) An offense under this section is a misdemeanor |
|
punishable by a fine of not less than $500 or more than $5,000. |
|
SECTION 2. Subtitle J, Title 3, Occupations Code, is |
|
amended by adding Chapter 570 to read as follows: |
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CHAPTER 570. REGULATION OF PHARMACY BENEFIT MANAGERS |
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SUBCHAPTER A. GENERAL PROVISIONS |
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Sec. 570.001. DEFINITIONS. In this chapter: |
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(1) "Commissioner" means the commissioner of |
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insurance. |
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(2) "Department" means the Texas Department of |
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Insurance. |
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(3) "Pharmacy benefit manager" has the meaning |
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assigned by Section 4154.001, Insurance Code. |
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[Sections 570.002-570.050 reserved for expansion] |
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SUBCHAPTER B. LICENSE REQUIREMENTS |
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Sec. 570.051. LICENSE REQUIRED; DEPARTMENT CERTIFICATE OF |
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AUTHORITY REQUIRED. (a) A person may not act as or represent that |
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the person is a pharmacy benefit manager in this state unless the |
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person holds a pharmacy benefit manager license issued by the board |
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under this chapter. |
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(b) In addition to the license issued by the board under |
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this chapter, a person may not act as or represent that the person |
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is a pharmacy benefit manager in this state unless the person is |
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covered by and is engaging in business under a certificate of |
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authority issued by the commissioner under Chapter 4154, Insurance |
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Code. |
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Sec. 570.052. LICENSE REQUIREMENTS. (a) The board by rule |
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shall adopt the requirements for an original or renewal license |
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issued under this chapter. |
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(b) In adopting rules under this section, the board shall |
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consider the requirements adopted by the commissioner under Chapter |
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4154, Insurance Code. |
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Sec. 570.053. LICENSE APPLICATION. Each applicant for a |
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license under this chapter shall submit a license application in |
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the manner prescribed by the board, accompanied by a nonrefundable |
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$500 application fee. |
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Sec. 570.054. INVESTIGATIONS. As the board considers |
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necessary for the protection of the residents of this state, the |
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board may conduct investigations regarding the quality of the |
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services provided by: |
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(1) a pharmacy benefit manager; or |
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(2) a pharmacy or pharmacist with whom the pharmacy |
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benefit manager contracts. |
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[Sections 570.055-570.100 reserved for expansion] |
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SUBCHAPTER C. PROHIBITED ACTS |
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Sec. 570.101. GENERAL PROHIBITED ACTS. A person licensed |
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under this chapter and doing business as a pharmacy benefit manager |
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may not: |
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(1) intervene in the delivery or transmission of |
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prescriptions from a prescribing health care practitioner to a |
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pharmacy or pharmacist for purposes of influencing the prescribing |
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health care practitioner's choice of therapy; |
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(2) attempt to influence an insured's, member's, or |
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enrollee's choice of pharmacy or pharmacist; or |
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(3) change a drug or device prescribed by a health care |
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practitioner without the written consent of the prescribing health |
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care practitioner. |
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Sec. 570.102. LICENSE TO PRACTICE PHARMACY REQUIRED. |
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Unless a person licensed under this chapter and doing business as a |
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pharmacy benefit manager also holds a license to practice pharmacy |
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issued by the board under Chapter 558, the person may not: |
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(1) provide pharmaceutical care or patient |
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counseling; |
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(2) interpret or evaluate a prescription drug order; |
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(3) participate in prescription drug or device |
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selection, administration, or regimen review; |
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(4) dispense or distribute drug orders or products; or |
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(5) perform a specific act of drug therapy for an |
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insured, member, or enrollee. |
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[Sections 570.103-570.150 reserved for expansion] |
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SUBCHAPTER D. ENFORCEMENT |
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Sec. 570.151. ENFORCEMENT; RULES. The board shall adopt |
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rules as necessary to enforce this chapter. In adopting rules under |
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this section, the board shall consult and cooperate with the |
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commissioner as necessary to coordinate enforcement of the license |
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requirements adopted under this chapter with the certificate of |
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authority requirements adopted under Chapter 4154, Insurance Code. |
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Sec. 570.152. COMPLAINTS; INVESTIGATION. (a) The board by |
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rule shall adopt procedures under Chapter 555 for investigation of |
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complaints concerning the failure of a pharmacy benefit manager to |
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comply with this chapter. |
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(b) The board shall refer a complaint received under this |
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chapter to the commissioner if the complaint involves an issue |
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regarding the business operations or finances of the pharmacy |
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benefit manager. |
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Sec. 570.153. DISCIPLINARY ACTIONS. If the board has |
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reason to believe that a violation of this chapter has occurred, the |
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board may, after notice and hearing: |
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(1) issue a cease and desist order against the |
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pharmacy benefit manager; or |
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(2) take any other necessary or appropriate action |
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under this subtitle, including suspension or revocation of the |
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pharmacy benefit manager's license. |
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SECTION 3. Section 4151.001(1), Insurance Code, is amended |
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to read as follows: |
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(1) "Administrator" means a person who, in connection |
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with annuities or life, health, and accident benefits, other than |
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[including] pharmacy benefits, collects premiums or contributions |
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from or adjusts or settles claims for residents of this state. The |
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term does not include: |
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(A) a person described by Section 4151.002; or |
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(B) a pharmacy benefit manager regulated under |
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Chapter 4154. |
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SECTION 4. Subchapter D, Chapter 4151, Insurance Code, is |
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repealed. |
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SECTION 5. (a) This section applies only to a person who: |
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(1) on the effective date of this Act, holds a |
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certificate of authority issued under Chapter 4151, Insurance Code; |
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and |
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(2) immediately before the effective date of this Act |
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is operating as a pharmacy benefit manager under that chapter. |
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(b) Notwithstanding any other provision of this Act, a |
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person to whom this section applies is entitled to an initial |
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certificate of authority under Chapter 4154, Insurance Code, as |
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added by this Act, if the person applies to the commissioner of |
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insurance in writing not later than March 1, 2008. The person is |
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not required to comply with the application requirements adopted |
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under Subchapter B, Chapter 4154, Insurance Code, as added by this |
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Act, if the commissioner of insurance determines that the person is |
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in compliance with the application and fidelity bond requirements |
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imposed under Subchapter B, Chapter 4151, Insurance Code. |
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(c) The commissioner of insurance shall adopt rules as |
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necessary to implement this section. |
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(d) This section expires July 1, 2008. |
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SECTION 6. A person is not required to hold a certificate of |
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authority under Chapter 4154, Insurance Code, as added by this Act, |
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or a license under Chapter 570, Occupations Code, as added by this |
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Act, to operate as a pharmacy benefit manager in this state until |
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January 1, 2008. |
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SECTION 7. (a) The commissioner of insurance shall adopt |
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rules as necessary to implement Chapter 4154, Insurance Code, as |
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added by this Act, not later than December 31, 2007. |
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(b) The Texas State Board of Pharmacy shall adopt rules as |
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necessary to implement Chapter 570, Occupations Code, as added by |
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this Act, not later than December 31, 2007. |
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SECTION 8. (a) Except as provided by Subsection (b) of this |
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section, this Act takes effect September 1, 2007. |
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(b) Sections 4154.051, 4154.304, and 4154.305, Insurance |
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Code, and Section 570.051, Occupations Code, take effect January 1, |
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2008. |