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|
A BILL TO BE ENTITLED
|
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|
AN ACT
|
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|
relating to contracts between governmental entities and pharmacy |
|
|
benefit managers. |
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|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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|
SECTION 1. Subchapter B, Chapter 531, Government Code, is |
|
|
amended by adding Sections 531.0741, 531.0742, 531.0743, 531.0744, |
|
|
531.0745, and 531.0746 to read as follows: |
|
|
Sec. 531.0741. TREATMENT OF CERTAIN REVENUE FROM |
|
|
PHARMACEUTICAL MANUFACTURERS IN CONTRACTS WITH PHARMACY BENEFIT |
|
|
MANAGERS. (a) In this section, "pharmacy benefit manager" means a |
|
|
person, other than a pharmacy or pharmacist, who acts as an |
|
|
administrator in connection with pharmacy benefits. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to any program under the jurisdiction of the |
|
|
commission must provide that: |
|
|
(1) with respect to any transaction with a |
|
|
pharmaceutical manufacturer or labeler in relation to the program, |
|
|
the pharmacy benefit manager represents the interests of the |
|
|
program; and |
|
|
(2) any compensation provided by a pharmaceutical |
|
|
manufacturer or labeler to the pharmacy benefit manager in relation |
|
|
to the program must be remitted to the commission for deposit to the |
|
|
credit of the general revenue fund, including compensation provided |
|
|
for formulary management and drug-switch programs, educational |
|
|
support, claims processing and pharmacy network fees that are |
|
|
charged from retail pharmacies, and data sales fees. |
|
|
Sec. 531.0742. SPECIALTY PHARMACY SERVICES. (a) In this |
|
|
section: |
|
|
(1) "Pharmacy benefit manager" means a person, other |
|
|
than a pharmacy or pharmacist, who acts as an administrator in |
|
|
connection with pharmacy benefits. |
|
|
(2) "Specialty pharmacy service" means a service |
|
|
offered by a pharmacy benefit manager in relation to benefits that |
|
|
involve chronic conditions, unusually high treatment costs, or |
|
|
management of complex care issues. The term specifically includes |
|
|
the provision of pharmaceutical benefits involving: |
|
|
(A) injectable and infusion therapies; |
|
|
(B) therapies with annual costs to the patient of |
|
|
$5,000 or more; and |
|
|
(C) therapies requiring complex care. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to any program under the jurisdiction of the |
|
|
commission that includes specialty pharmacy services must provide |
|
|
that the pharmacy benefit manager shall: |
|
|
(1) pass through to the commission for deposit in the |
|
|
general revenue fund 100 percent of any revenue associated with |
|
|
distribution of a specialty pharmacy product paid by a |
|
|
pharmaceutical manufacturer or labeler to the pharmacy benefit |
|
|
manager; |
|
|
(2) agree to charge the commission on an acquisition |
|
|
cost basis, which may include a dispensing fee, for all specialty |
|
|
pharmacy prescriptions, based on actual inventory costs or |
|
|
wholesale acquisition cost; and |
|
|
(3) provide case management for critical disease |
|
|
conditions, as specified by the contract, and agree not to |
|
|
incorporate the costs of the case management into the costs |
|
|
assessed for drug ingredients for the specialty pharmacy product. |
|
|
Sec. 531.0743. MAIL ORDER PHARMACY SERVICES. (a) In this |
|
|
section: |
|
|
(1) "Mail order pharmacy" means a pharmacy that is |
|
|
licensed as a Class A or Class E pharmacy under Chapter 560, |
|
|
Occupations Code, and that primarily delivers prescription drugs to |
|
|
an enrollee through the United States Postal Service or a |
|
|
commercial delivery service. |
|
|
(2) "Pharmacy benefit manager" means a person, other |
|
|
than a pharmacy or pharmacist, who acts as an administrator in |
|
|
connection with pharmacy benefits. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to any program under the jurisdiction of the |
|
|
commission that includes pharmacy services must provide that the |
|
|
pharmacy benefit manager shall agree to charge the commission on an |
|
|
acquisition cost basis, which may include a dispensing fee, for all |
|
|
prescriptions filled by a mail order pharmacy, based on actual |
|
|
inventory costs or wholesale acquisition cost. |
|
|
Sec. 531.0744. AMOUNTS CHARGED BY PHARMACY BENEFIT MANAGERS |
|
|
FOR CERTAIN CLAIMS. (a) In this section, "pharmacy benefit |
|
|
manager" means a person, other than a pharmacy or pharmacist, who |
|
|
acts as an administrator in connection with pharmacy benefits. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to any program under the jurisdiction of the |
|
|
commission must provide that the pharmacy benefit manager may not |
|
|
charge the program an amount for a brand retail claim payment or |
|
|
generic retail claim payment that is more than the amount the |
|
|
pharmacy benefit manager pays a pharmacy in the pharmacy benefit |
|
|
manager's retail network for the same claim. |
|
|
Sec. 531.0745. AUDIT OF PHARMACY BENEFIT MANAGERS. (a) In |
|
|
this section, "pharmacy benefit manager" means a person, other than |
|
|
a pharmacy or pharmacist, who acts as an administrator in |
|
|
connection with pharmacy benefits. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to any program under the jurisdiction of the |
|
|
commission must provide that the commission, using an auditor |
|
|
selected by the commission, may audit: |
|
|
(1) the program's pharmacy benefit claims; |
|
|
(2) the pharmacy benefit manager's contracts with |
|
|
pharmacies and pharmaceutical manufacturers and labelers; |
|
|
(3) the pharmacy benefit manager's utilization |
|
|
management clinical criteria; and |
|
|
(4) mail service purchasing invoices related to |
|
|
benefits provided under the program. |
|
|
(c) This section does not affect the state auditor's |
|
|
authority to access information or conduct an audit. |
|
|
Sec. 531.0746. PHARMACY BENEFIT MANAGERS: DESIGNATION OF |
|
|
CONFIDENTIAL INFORMATION. (a) A pharmacy benefit manager may |
|
|
designate as confidential any information the pharmacy benefit |
|
|
manager is required to disclose to comply with Section 531.0741, |
|
|
531.0742, 531.0743, 531.0744, or 531.0745. |
|
|
(b) Information designated as confidential under this |
|
|
section may not be disclosed by the commission to any person without |
|
|
the consent of the pharmacy benefit manager unless the disclosure |
|
|
is: |
|
|
(1) ordered by a court for good cause shown; |
|
|
(2) made under seal in a court filing; or |
|
|
(3) made to the commissioner of insurance or the |
|
|
attorney general in connection with an investigation authorized by |
|
|
this code, the Insurance Code, or any other law. |
|
|
SECTION 2. Subchapter D, Chapter 1001, Health and Safety |
|
|
Code, is amended by adding Sections 1001.076, 1001.077, 1001.078, |
|
|
1001.079, 1001.080, and 1001.081 to read as follows: |
|
|
Sec. 1001.076. TREATMENT OF CERTAIN REVENUE FROM |
|
|
PHARMACEUTICAL MANUFACTURERS IN CONTRACTS WITH PHARMACY BENEFIT |
|
|
MANAGERS. (a) In this section, "pharmacy benefit manager" means a |
|
|
person, other than a pharmacy or pharmacist, who acts as an |
|
|
administrator in connection with pharmacy benefits. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to any program under the jurisdiction of the |
|
|
department must provide that: |
|
|
(1) with respect to any transaction with a |
|
|
pharmaceutical manufacturer or labeler in relation to the program, |
|
|
the pharmacy benefit manager represents the interests of the |
|
|
program; and |
|
|
(2) any compensation provided by a pharmaceutical |
|
|
manufacturer or labeler to the pharmacy benefit manager in relation |
|
|
to the program must be remitted to the department for deposit to the |
|
|
credit of the general revenue fund, including compensation provided |
|
|
for formulary management and drug-switch programs, educational |
|
|
support, claims processing and pharmacy network fees that are |
|
|
charged from retail pharmacies, and data sales fees. |
|
|
Sec. 1001.077. SPECIALTY PHARMACY SERVICES. (a) In this |
|
|
section: |
|
|
(1) "Pharmacy benefit manager" means a person, other |
|
|
than a pharmacy or pharmacist, who acts as an administrator in |
|
|
connection with pharmacy benefits. |
|
|
(2) "Specialty pharmacy service" means a service |
|
|
offered by a pharmacy benefit manager in relation to benefits that |
|
|
involve chronic conditions, unusually high treatment costs, or |
|
|
management of complex care issues. The term specifically includes |
|
|
the provision of pharmaceutical benefits involving: |
|
|
(A) injectable and infusion therapies; |
|
|
(B) therapies with annual costs to the patient of |
|
|
$5,000 or more; and |
|
|
(C) therapies requiring complex care. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to any program under the jurisdiction of the |
|
|
department that includes specialty pharmacy services must provide |
|
|
that the pharmacy benefit manager shall: |
|
|
(1) pass through to the department for deposit in the |
|
|
general revenue fund 100 percent of any of the revenue associated |
|
|
with distribution of a specialty pharmacy product paid by a |
|
|
pharmaceutical manufacturer or labeler to the pharmacy benefit |
|
|
manager; |
|
|
(2) agree to charge the department on an acquisition |
|
|
cost basis, which may include a dispensing fee, for all specialty |
|
|
pharmacy prescriptions, based on actual inventory costs or |
|
|
wholesale acquisition cost; and |
|
|
(3) provide case management for critical disease |
|
|
conditions, as specified by the contract, and agree not to |
|
|
incorporate the costs of the case management into the costs |
|
|
assessed for drug ingredients for the specialty pharmacy product. |
|
|
Sec. 1001.078. MAIL ORDER PHARMACY SERVICES. (a) In this |
|
|
section: |
|
|
(1) "Mail order pharmacy" means a pharmacy that is |
|
|
licensed as a Class A or Class E pharmacy under Chapter 560, |
|
|
Occupations Code, and that primarily delivers prescription drugs to |
|
|
an enrollee through the United States Postal Service or a |
|
|
commercial delivery service. |
|
|
(2) "Pharmacy benefit manager" means a person, other |
|
|
than a pharmacy or pharmacist, who acts as an administrator in |
|
|
connection with pharmacy benefits. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to any program under the jurisdiction of the |
|
|
department that includes pharmacy services must provide that the |
|
|
pharmacy benefit manager shall agree to charge the department on an |
|
|
acquisition cost basis, which may include a dispensing fee, for all |
|
|
prescriptions filled by a mail order pharmacy, based on actual |
|
|
inventory costs or wholesale acquisition cost. |
|
|
Sec. 1001.079. AMOUNTS CHARGED BY PHARMACY BENEFIT MANAGERS |
|
|
FOR CERTAIN CLAIMS. (a) In this section, "pharmacy benefit |
|
|
manager" means a person, other than a pharmacy or pharmacist, who |
|
|
acts as an administrator in connection with pharmacy benefits. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to any program under the jurisdiction of the |
|
|
department must provide that the pharmacy benefit manager may not |
|
|
charge the program an amount for a brand retail claim payment or |
|
|
generic retail claim payment that is more than the amount the |
|
|
pharmacy benefit manager pays a pharmacy in the pharmacy benefit |
|
|
manager's retail network for the same claim. |
|
|
Sec. 1001.080. AUDIT OF PHARMACY BENEFIT MANAGERS. (a) In |
|
|
this section, "pharmacy benefit manager" means a person, other than |
|
|
a pharmacy or pharmacist, who acts as an administrator in |
|
|
connection with pharmacy benefits. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to any program under the jurisdiction of the |
|
|
department must provide that the department, using an auditor |
|
|
selected by the department, may audit: |
|
|
(1) the program's pharmacy benefit claims; |
|
|
(2) the pharmacy benefit manager's contracts with |
|
|
pharmacies and pharmaceutical manufacturers and labelers; |
|
|
(3) the pharmacy benefit manager's utilization |
|
|
management clinical criteria; and |
|
|
(4) mail service purchasing invoices related to |
|
|
benefits provided under the program. |
|
|
(c) This section does not affect the state auditor's |
|
|
authority to access information or conduct an audit. |
|
|
Sec. 1001.081. PHARMACY BENEFIT MANAGERS: DESIGNATION OF |
|
|
CONFIDENTIAL INFORMATION. (a) A pharmacy benefit manager may |
|
|
designate as confidential any information the pharmacy benefit |
|
|
manager is required to disclose to comply with Section 1001.076, |
|
|
1001.077, 1001.078, 1001.079, or 1001.080. |
|
|
(b) Information designated as confidential under this |
|
|
section may not be disclosed by the department to any person without |
|
|
the consent of the pharmacy benefit manager unless the disclosure |
|
|
is: |
|
|
(1) ordered by a court for good cause shown; |
|
|
(2) made under seal in a court filing; or |
|
|
(3) made to the commissioner of insurance or the |
|
|
attorney general in connection with an investigation authorized by |
|
|
this code, the Insurance Code, or any other law. |
|
|
SECTION 3. Subchapter B, Chapter 1551, Insurance Code, is |
|
|
amended by adding Sections 1551.068, 1551.069, 1551.070, 1551.071, |
|
|
1551.072, and 1551.073 to read as follows: |
|
|
Sec. 1551.068. TREATMENT OF CERTAIN REVENUE FROM |
|
|
PHARMACEUTICAL MANUFACTURERS IN CONTRACTS WITH PHARMACY BENEFIT |
|
|
MANAGERS. (a) In this section, "pharmacy benefit manager" means an |
|
|
administering firm or other person, other than a pharmacy or |
|
|
pharmacist, who acts as an administrator in connection with |
|
|
pharmacy benefits. The term includes an administrator subject to |
|
|
Chapter 4151 who administers pharmacy benefits. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to the group benefits program must provide that: |
|
|
(1) with respect to any transaction with a |
|
|
pharmaceutical manufacturer or labeler in relation to the program, |
|
|
the pharmacy benefit manager represents the interests of the |
|
|
program; and |
|
|
(2) any compensation provided by a pharmaceutical |
|
|
manufacturer or labeler to the pharmacy benefit manager in relation |
|
|
to the program must be remitted to the board of trustees for deposit |
|
|
to the credit of the employees life, accident, and health insurance |
|
|
and benefits fund, including compensation provided for formulary |
|
|
management and drug-switch programs, educational support, claims |
|
|
processing and pharmacy network fees that are charged from retail |
|
|
pharmacies, and data sales fees. |
|
|
Sec. 1551.069. SPECIALTY PHARMACY SERVICES. (a) In this |
|
|
section: |
|
|
(1) "Pharmacy benefit manager" means an administering |
|
|
firm or other person, other than a pharmacy or pharmacist, who acts |
|
|
as an administrator in connection with pharmacy benefits. The term |
|
|
includes an administrator subject to Chapter 4151 who administers |
|
|
pharmacy benefits. |
|
|
(2) "Specialty pharmacy service" means a service |
|
|
offered by a pharmacy benefit manager in relation to benefits that |
|
|
involve chronic conditions, unusually high treatment costs, or |
|
|
management of complex care issues. The term specifically includes |
|
|
the provision of pharmaceutical benefits involving: |
|
|
(A) injectable and infusion therapies; |
|
|
(B) therapies with annual costs to the patient of |
|
|
$5,000 or more; and |
|
|
(C) therapies requiring complex care. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to the group benefits program that includes specialty |
|
|
pharmacy services must provide that the pharmacy benefit manager |
|
|
shall: |
|
|
(1) pass through to the board of trustees for deposit |
|
|
to the credit of the employees life, accident, and health insurance |
|
|
and benefits fund 100 percent of any revenue associated with |
|
|
distribution of a specialty pharmacy product paid by a |
|
|
pharmaceutical manufacturer or labeler to the pharmacy benefit |
|
|
manager; |
|
|
(2) agree to charge the board of trustees on an |
|
|
acquisition cost basis, which may include a dispensing fee, for all |
|
|
specialty pharmacy prescriptions, based on actual inventory costs |
|
|
or wholesale acquisition cost; and |
|
|
(3) provide case management for critical disease |
|
|
conditions, as specified by the contract, and agree not to |
|
|
incorporate the costs of the case management into the costs |
|
|
assessed for drug ingredients for the specialty pharmacy product. |
|
|
Sec. 1551.070. MAIL ORDER PHARMACY SERVICES. (a) In this |
|
|
section: |
|
|
(1) "Mail order pharmacy" means a pharmacy that is |
|
|
licensed as a Class A or Class E pharmacy under Chapter 560, |
|
|
Occupations Code, and that primarily delivers prescription drugs to |
|
|
an enrollee through the United States Postal Service or a |
|
|
commercial delivery service. |
|
|
(2) "Pharmacy benefit manager" means an administering |
|
|
firm or other person, other than a pharmacy or pharmacist, who acts |
|
|
as an administrator in connection with pharmacy benefits. The term |
|
|
includes an administrator subject to Chapter 4151 who administers |
|
|
pharmacy benefits. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to the group benefits program that includes pharmacy |
|
|
services must provide that the pharmacy benefit manager shall agree |
|
|
to charge the board of trustees on an acquisition cost basis, which |
|
|
may include a dispensing fee, for all prescriptions filled by a mail |
|
|
order pharmacy, based on actual inventory costs or wholesale |
|
|
acquisition cost. |
|
|
Sec. 1551.071. AMOUNTS CHARGED BY PHARMACY BENEFIT MANAGERS |
|
|
FOR CERTAIN CLAIMS. (a) In this section, "pharmacy benefit |
|
|
manager" means an administering firm or other person, other than a |
|
|
pharmacy or pharmacist, who acts as an administrator in connection |
|
|
with pharmacy benefits. The term includes an administrator subject |
|
|
to Chapter 4151 who administers pharmacy benefits. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to the group benefits program must provide that the |
|
|
pharmacy benefit manager may not charge the program an amount for a |
|
|
brand retail claim payment or generic retail claim payment that is |
|
|
more than the amount the pharmacy benefit manager pays a pharmacy in |
|
|
the pharmacy benefit manager's retail network for the same claim. |
|
|
Sec. 1551.072. AUDIT OF PHARMACY BENEFIT MANAGERS. (a) In |
|
|
this section, "pharmacy benefit manager" means an administering |
|
|
firm or other person, other than a pharmacy or pharmacist, who acts |
|
|
as an administrator in connection with pharmacy benefits. The term |
|
|
includes an administrator subject to Chapter 4151 who administers |
|
|
pharmacy benefits. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to the group benefits program must provide that the |
|
|
board of trustees, using an auditor selected by the board of |
|
|
trustees, may audit: |
|
|
(1) the program's pharmacy benefit claims; |
|
|
(2) the pharmacy benefit manager's contracts with |
|
|
pharmacies and pharmaceutical manufacturers and labelers; |
|
|
(3) the pharmacy benefit manager's utilization |
|
|
management clinical criteria; and |
|
|
(4) mail service purchasing invoices related to |
|
|
benefits provided under the program. |
|
|
(c) This section does not affect the state auditor's |
|
|
authority to access information or conduct an audit. |
|
|
Sec. 1551.073. PHARMACY BENEFIT MANAGERS: DESIGNATION OF |
|
|
CONFIDENTIAL INFORMATION. (a) A pharmacy benefit manager may |
|
|
designate as confidential any information the pharmacy benefit |
|
|
manager is required to disclose to comply with Section 1551.068, |
|
|
1551.069, 1551.070, 1551.071, or 1551.072. |
|
|
(b) Information designated as confidential under this |
|
|
section may not be disclosed by the board of trustees to any person |
|
|
without the consent of the pharmacy benefit manager unless the |
|
|
disclosure is: |
|
|
(1) ordered by a court for good cause shown; |
|
|
(2) made under seal in a court filing; or |
|
|
(3) made to the commissioner or the attorney general |
|
|
in connection with an investigation authorized by this code or any |
|
|
other law. |
|
|
SECTION 4. Subchapter B, Chapter 1575, Insurance Code, is |
|
|
amended by adding Sections 1575.057, 1575.058, 1575.059, 1575.060, |
|
|
1575.061, and 1575.062 to read as follows: |
|
|
Sec. 1575.057. TREATMENT OF CERTAIN REVENUE FROM |
|
|
PHARMACEUTICAL MANUFACTURERS IN CONTRACTS WITH PHARMACY BENEFIT |
|
|
MANAGERS. (a) In this section, "pharmacy benefit manager" means a |
|
|
person, other than a pharmacy or pharmacist, who acts as an |
|
|
administrator in connection with pharmacy benefits. The term |
|
|
includes an administrator subject to Chapter 4151 who administers |
|
|
pharmacy benefits. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to the group program must provide that: |
|
|
(1) with respect to any transaction with a |
|
|
pharmaceutical manufacturer or labeler in relation to the program, |
|
|
the pharmacy benefit manager represents the interests of the |
|
|
program; and |
|
|
(2) any compensation provided by a pharmaceutical |
|
|
manufacturer or labeler to the pharmacy benefit manager in relation |
|
|
to the program must be remitted to the trustee for deposit to the |
|
|
credit of the retired school employees group insurance fund, |
|
|
including compensation provided for formulary management and |
|
|
drug-switch programs, educational support, claims processing and |
|
|
pharmacy network fees that are charged from retail pharmacies, and |
|
|
data sales fees. |
|
|
Sec. 1575.058. SPECIALTY PHARMACY SERVICES. (a) In this |
|
|
section: |
|
|
(1) "Pharmacy benefit manager" means an administering |
|
|
firm or other person, other than a pharmacy or pharmacist, who acts |
|
|
as an administrator in connection with pharmacy benefits. The term |
|
|
includes an administrator subject to Chapter 4151 who administers |
|
|
pharmacy benefits. |
|
|
(2) "Specialty pharmacy service" means a service |
|
|
offered by a pharmacy benefit manager in relation to benefits that |
|
|
involve chronic conditions, unusually high treatment costs, or |
|
|
management of complex care issues. The term specifically includes |
|
|
the provision of pharmaceutical benefits involving: |
|
|
(A) injectable and infusion therapies; |
|
|
(B) therapies with annual costs to the patient of |
|
|
$5,000 or more; and |
|
|
(C) therapies requiring complex care. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to the group program that includes specialty pharmacy |
|
|
services must provide that the pharmacy benefit manager shall: |
|
|
(1) pass through to the trustee for deposit to the |
|
|
credit of the retired school employees group insurance fund 100 |
|
|
percent of any revenue associated with distribution of a specialty |
|
|
pharmacy product paid by a pharmaceutical manufacturer or labeler |
|
|
to the pharmacy benefit manager; |
|
|
(2) agree to charge the trustee on an acquisition cost |
|
|
basis, which may include a dispensing fee, for all specialty |
|
|
pharmacy prescriptions, based on actual inventory costs or |
|
|
wholesale acquisition cost; and |
|
|
(3) provide case management for critical disease |
|
|
conditions, as specified by the contract, and agree not to |
|
|
incorporate the costs of the case management into the costs |
|
|
assessed for drug ingredients for the specialty pharmacy product. |
|
|
Sec. 1575.059. MAIL ORDER PHARMACY SERVICES. (a) In this |
|
|
section: |
|
|
(1) "Mail order pharmacy" means a pharmacy that is |
|
|
licensed as a Class A or Class E pharmacy under Chapter 560, |
|
|
Occupations Code, and that primarily delivers prescription drugs to |
|
|
an enrollee through the United States Postal Service or a |
|
|
commercial delivery service. |
|
|
(2) "Pharmacy benefit manager" means an administering |
|
|
firm or other person, other than a pharmacy or pharmacist, who acts |
|
|
as an administrator in connection with pharmacy benefits. The term |
|
|
includes an administrator subject to Chapter 4151 who administers |
|
|
pharmacy benefits. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to the group program that includes pharmacy services |
|
|
must provide that the pharmacy benefit manager shall agree to |
|
|
charge the trustee on an acquisition cost basis, which may include a |
|
|
dispensing fee, for all prescriptions filled by a mail order |
|
|
pharmacy, based on actual inventory costs or wholesale acquisition |
|
|
cost. |
|
|
Sec. 1575.060. AMOUNTS CHARGED BY PHARMACY BENEFIT MANAGERS |
|
|
FOR CERTAIN CLAIMS. (a) In this section, "pharmacy benefit |
|
|
manager" means a person, other than a pharmacy or pharmacist, who |
|
|
acts as an administrator in connection with pharmacy benefits. The |
|
|
term includes an administrator subject to Chapter 4151 who |
|
|
administers pharmacy benefits. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to the group program must provide that the pharmacy |
|
|
benefit manager may not charge the program an amount for a brand |
|
|
retail claim payment or generic retail claim payment that is more |
|
|
than the amount the pharmacy benefit manager pays a pharmacy in the |
|
|
pharmacy benefit manager's retail network for the same claim. |
|
|
Sec. 1575.061. AUDIT OF PHARMACY BENEFIT MANAGERS. (a) In |
|
|
this section, "pharmacy benefit manager" means a person, other than |
|
|
a pharmacy or pharmacist, who acts as an administrator in |
|
|
connection with pharmacy benefits. The term includes an |
|
|
administrator subject to Chapter 4151 who administers pharmacy |
|
|
benefits. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to the group program must provide that the trustee, |
|
|
using an auditor selected by the trustee, may audit: |
|
|
(1) the program's pharmacy benefit claims; |
|
|
(2) the pharmacy benefit manager's contracts with |
|
|
pharmacies and pharmaceutical manufacturers and labelers; |
|
|
(3) the pharmacy benefit manager's utilization |
|
|
management clinical criteria; and |
|
|
(4) mail service purchasing invoices related to |
|
|
benefits provided under the program. |
|
|
(c) This section does not affect the state auditor's |
|
|
authority to access information or conduct an audit. |
|
|
Sec. 1575.062. PHARMACY BENEFIT MANAGERS: DESIGNATION OF |
|
|
CONFIDENTIAL INFORMATION. (a) A pharmacy benefit manager may |
|
|
designate as confidential any information the pharmacy benefit |
|
|
manager is required to disclose to comply with Section 1575.057, |
|
|
1575.058, 1575.059, 1575.060, or 1575.061. |
|
|
(b) Information designated as confidential under this |
|
|
section may not be disclosed by the trustee to any person without |
|
|
the consent of the pharmacy benefit manager unless the disclosure |
|
|
is: |
|
|
(1) ordered by a court for good cause shown; |
|
|
(2) made under seal in a court filing; or |
|
|
(3) made to the commissioner or the attorney general |
|
|
in connection with an investigation authorized by this code or any |
|
|
other law. |
|
|
SECTION 5. Subchapter B, Chapter 1579, Insurance Code, is |
|
|
amended by adding Sections 1579.056, 1579.057, 1579.058, 1579.059, |
|
|
1579.060, and 1579.061 to read as follows: |
|
|
Sec. 1579.056. TREATMENT OF CERTAIN REVENUE FROM |
|
|
PHARMACEUTICAL MANUFACTURERS IN CONTRACTS WITH PHARMACY BENEFIT |
|
|
MANAGERS. (a) In this section, "pharmacy benefit manager" means an |
|
|
administering firm or other person, other than a pharmacy or |
|
|
pharmacist, who acts as an administrator in connection with |
|
|
pharmacy benefits. The term includes an administrator subject to |
|
|
Chapter 4151 who administers pharmacy benefits. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to the program must provide that: |
|
|
(1) with respect to any transaction with a |
|
|
pharmaceutical manufacturer or labeler in relation to the program, |
|
|
the pharmacy benefit manager represents the interests of the |
|
|
program; and |
|
|
(2) any compensation provided by a pharmaceutical |
|
|
manufacturer or labeler to the pharmacy benefit manager in relation |
|
|
to the program must be remitted to the trustee for deposit to the |
|
|
credit of the Texas school employees uniform group coverage trust |
|
|
fund, including compensation provided for formulary management and |
|
|
drug-switch programs, educational support, claims processing and |
|
|
pharmacy network fees that are charged from retail pharmacies, and |
|
|
data sales fees. |
|
|
Sec. 1579.057. SPECIALTY PHARMACY SERVICES. (a) In this |
|
|
section: |
|
|
(1) "Pharmacy benefit manager" means an administering |
|
|
firm or other person, other than a pharmacy or pharmacist, who acts |
|
|
as an administrator in connection with pharmacy benefits. The term |
|
|
includes an administrator subject to Chapter 4151 who administers |
|
|
pharmacy benefits. |
|
|
(2) "Specialty pharmacy service" means a service |
|
|
offered by a pharmacy benefit manager in relation to benefits that |
|
|
involve chronic conditions, unusually high treatment costs, or |
|
|
management of complex care issues. The term specifically includes |
|
|
the provision of pharmaceutical benefits involving: |
|
|
(A) injectable and infusion therapies; |
|
|
(B) therapies with annual costs to the patient of |
|
|
$5,000 or more; and |
|
|
(C) therapies requiring complex care. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to the program that includes specialty pharmacy |
|
|
services must provide that the pharmacy benefit manager shall: |
|
|
(1) pass through to the trustee for deposit to the |
|
|
credit of the Texas school employees uniform group coverage trust |
|
|
fund 100 percent of any revenue associated with distribution of a |
|
|
specialty pharmacy product paid by a pharmaceutical manufacturer or |
|
|
labeler to the pharmacy benefit manager; |
|
|
(2) agree to charge the trustee on an acquisition cost |
|
|
basis, which may include a dispensing fee, for all specialty |
|
|
pharmacy prescriptions, based on actual inventory costs or |
|
|
wholesale acquisition cost; and |
|
|
(3) provide case management for critical disease |
|
|
conditions, as specified by the contract, and agree not to |
|
|
incorporate the costs of the case management into the costs |
|
|
assessed for drug ingredients for the specialty pharmacy product. |
|
|
Sec. 1579.058. MAIL ORDER PHARMACY SERVICES. (a) In this |
|
|
section: |
|
|
(1) "Mail order pharmacy" means a pharmacy that is |
|
|
licensed as a Class A or Class E pharmacy under Chapter 560, |
|
|
Occupations Code, and that primarily delivers prescription drugs to |
|
|
an enrollee through the United States Postal Service or a |
|
|
commercial delivery service. |
|
|
(2) "Pharmacy benefit manager" means an administering |
|
|
firm or other person, other than a pharmacy or pharmacist, who acts |
|
|
as an administrator in connection with pharmacy benefits. The term |
|
|
includes an administrator subject to Chapter 4151 who administers |
|
|
pharmacy benefits. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to the program that includes pharmacy services must |
|
|
provide that the pharmacy benefit manager shall agree to charge the |
|
|
trustee on an acquisition cost basis, which may include a |
|
|
dispensing fee, for all prescriptions filled by a mail order |
|
|
pharmacy, based on actual inventory costs or wholesale acquisition |
|
|
cost. |
|
|
Sec. 1579.059. AMOUNTS CHARGED BY PHARMACY BENEFIT MANAGERS |
|
|
FOR CERTAIN CLAIMS. (a) In this section, "pharmacy benefit |
|
|
manager" means an administering firm or other person, other than a |
|
|
pharmacy or pharmacist, who acts as an administrator in connection |
|
|
with pharmacy benefits. The term includes an administrator subject |
|
|
to Chapter 4151 who administers pharmacy benefits. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to the program must provide that the pharmacy benefit |
|
|
manager may not charge the program an amount for a brand retail |
|
|
claim payment or generic retail claim payment that is more than the |
|
|
amount the pharmacy benefit manager pays a pharmacy in the pharmacy |
|
|
benefit manager's retail network for the same claim. |
|
|
Sec. 1579.060. AUDIT OF PHARMACY BENEFIT MANAGERS. (a) In |
|
|
this section, "pharmacy benefit manager" means an administering |
|
|
firm or other person, other than a pharmacy or pharmacist, who acts |
|
|
as an administrator in connection with pharmacy benefits. The term |
|
|
includes an administrator subject to Chapter 4151 who administers |
|
|
pharmacy benefits. |
|
|
(b) A contract with a pharmacy benefit manager entered into |
|
|
with respect to the program must provide that the trustee, using an |
|
|
auditor selected by the trustee, may audit: |
|
|
(1) the program's pharmacy benefit claims; |
|
|
(2) the pharmacy benefit manager's contracts with |
|
|
pharmacies and pharmaceutical manufacturers and labelers; |
|
|
(3) the pharmacy benefit manager's utilization |
|
|
management clinical criteria; and |
|
|
(4) mail service purchasing invoices related to |
|
|
benefits provided under the program. |
|
|
(c) This section does not affect the state auditor's |
|
|
authority to access information or conduct an audit. |
|
|
Sec. 1579.061. PHARMACY BENEFIT MANAGERS: DESIGNATION OF |
|
|
CONFIDENTIAL INFORMATION. (a) A pharmacy benefit manager may |
|
|
designate as confidential any information the pharmacy benefit |
|
|
manager is required to disclose to comply with Section 1579.056, |
|
|
1579.057, 1579.058, 1579.059, or 1579.060. |
|
|
(b) Information designated as confidential under this |
|
|
section may not be disclosed by the trustee to any person without |
|
|
the consent of the pharmacy benefit manager unless the disclosure |
|
|
is: |
|
|
(1) ordered by a court for good cause shown; |
|
|
(2) made under seal in a court filing; or |
|
|
(3) made to the commissioner or the attorney general |
|
|
in connection with an investigation authorized by this code or any |
|
|
other law. |
|
|
SECTION 6. The change in law made by this Act applies only |
|
|
to a contract with a pharmacy benefit manager executed or renewed on |
|
|
or after the effective date of this Act. |
|
|
SECTION 7. This Act takes effect immediately if it receives |
|
|
a vote of two-thirds of all the members elected to each house, as |
|
|
provided by Section 39, Article III, Texas Constitution. If this |
|
|
Act does not receive the vote necessary for immediate effect, this |
|
|
Act takes effect September 1, 2007. |