81R7767 KCR-F
 
  By: Watson S.B. No. 1433
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to the delivery of prescription drugs for certain state
  health plans by mail order; providing an administrative penalty.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Subtitle H, Title 8, Insurance Code, is amended
  by adding Chapter 1560 to read as follows:
  CHAPTER 1560. DELIVERY OF PRESCRIPTION DRUGS BY MAIL
         Sec. 1560.001.  DEFINITIONS. In this chapter:
               (1)  "Community retail pharmacy" means a pharmacy that
  is licensed as a Class A pharmacy under Chapter 560, Occupations
  Code.
               (2)  "Mail order pharmacy" means a pharmacy that is
  licensed 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.
               (3)  "Prescription drug formulary" means a list of
  prescription drugs preferred for use and eligible for coverage
  under a health benefit plan.
         Sec. 1560.002.  APPLICABILITY OF CHAPTER. This chapter
  applies only to a health benefit plan that provides benefits for
  medical or surgical expenses incurred as a result of a health
  condition, accident, or sickness, including an individual, group,
  blanket, or franchise insurance policy or insurance agreement, a
  group hospital service contract, or an individual or group evidence
  of coverage or similar coverage document that is offered or
  administered by:
               (1)  the Teacher Retirement System of Texas under
  Chapter 1575 or 1579; or
               (2)  the Employees Retirement System of Texas under
  Chapter 1551.
         Sec. 1560.003.  MULTIPLE-MONTH SUPPLY OF PRESCRIPTION DRUG.  
  (a)  In this section, "multiple-month supply" means a supply for 60
  or more days.
         (b)  Notwithstanding any other law, an issuer of a health
  benefit plan that provides pharmacy benefits to enrollees must
  allow an enrollee to obtain from a community retail pharmacy a
  multiple-month supply of any prescription drug under the same terms
  and conditions applicable when the prescription drug is obtained
  from a mail order pharmacy, if the community retail pharmacy agrees
  to accept reimbursement on exactly the same terms and conditions
  that apply to a mail order pharmacy.
         (c)  This section does not require:
               (1)  the issuer of a health benefit plan to contract
  with:
                     (A)  a retail pharmacy that does not agree to
  accept reimbursement on exactly the same terms and conditions that
  apply to a mail order pharmacy; or
                     (B)  more than one mail order pharmacy; or
               (2)  a community retail pharmacy to:
                     (A)  provide a multiple-month supply of a
  prescription drug under the same terms and conditions applicable
  when the prescription drug is obtained from a mail order pharmacy;
  or
                     (B)  agree to accept reimbursement on exactly the
  same terms and conditions that apply to a mail order pharmacy.
         Sec. 1560.004.  PRESCRIPTION DRUG REIMBURSEMENT RATES. (a)  
  An issuer of a health benefit plan that provides pharmacy benefits
  to enrollees shall reimburse pharmacies participating in the health
  plan using prescription drug reimbursement rates, for both brand
  name and generic prescription drugs, that are based on a current and
  nationally recognized benchmark index that includes average
  wholesale price and maximum allowable cost.
         (b)  Regardless of whether a pharmacy is a mail order
  pharmacy or a community retail pharmacy, an issuer of a health
  benefit plan shall use the same benchmark index, including the same
  average wholesale price, maximum allowable cost, and national
  prescription drug codes, to reimburse all pharmacies participating
  in the health benefit plan.
         Sec. 1560.005.  ACQUISITION COSTS AND REBATES.  An issuer of
  a health benefit plan that contracts with a third-party
  administrator, pharmacy benefit manager, or other entity to manage
  pharmacy benefits provided to enrollees through a mail order
  pharmacy shall require the managing entity to:
               (1)  provide the issuer of the health benefit plan with
  an annual electronic report containing:
                     (A)  the actual acquisition cost of all drugs
  purchased by the managing entity in relation to the pharmacy
  benefits under the health benefit plan; and
                     (B)  an identification of the source, type, and
  amount of all rebates, rebate administrative fees, and other
  monetary benefits received by the managing entity from a drug
  manufacturer in relation to the pharmacy benefits under the health
  benefit plan; and
               (2)  not later than the 30th day after the date the
  managing entity receives a rebate, rebate administrative fee, or
  other monetary benefit from a drug manufacturer in relation to the
  pharmacy benefits under the health benefit plan, reimburse or
  credit to the issuer of the health benefit plan an amount equal to
  the amount of the rebate, rebate administrative fee, or other
  monetary benefit received by the managing entity.
         Sec. 1560.006.  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 under Section 1560.005.
         (b)  Information designated as confidential under this
  section may not be disclosed 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 Government Code, or any other law.
         Sec. 1560.007.  COMPLAINT AND ENFORCEMENT; ADMINISTRATIVE
  PENALTIES. (a)  The department shall investigate any complaint
  that the department receives concerning conduct regulated by this
  chapter.
         (b)  Following an investigation under Subsection (a), the
  commissioner shall issue a written determination of the outcome of
  the investigation, including whether the department has taken or
  intends to take any action under Chapters 81-86.
         (c)  If, as a result of a complaint investigated under
  Subsection (a), the commissioner determines that an issuer of a
  health benefit plan has violated this chapter, the commissioner
  shall impose an administrative penalty against the issuer of the
  health benefit plan in accordance with Chapter 84. The amount of an
  administrative penalty imposed under this subsection may not exceed
  $1,000 per prescription that was filled or that was not filled in
  violation of this chapter. The limitation on the amount of an
  administrative penalty under Section 84.022 does not apply to an
  administrative penalty imposed under this subsection.
         SECTION 2.  Section 1551.224, Insurance Code, is amended to
  read as follows:
         Sec. 1551.224.  MAIL ORDER REQUIREMENT FOR PRESCRIPTION DRUG
  COVERAGE PROHIBITED. (a) The board of trustees or a health
  benefit plan under this chapter that provides benefits for
  prescription drugs may not require a participant in the group
  benefits program to purchase a prescription drug through a mail
  order program.
         (b)  Except as provided by Subsection (c), the [The] board of
  trustees or a health benefit plan shall require that a participant
  who chooses to obtain a prescription drug through a retail pharmacy
  or other method other than by mail order pay a deductible,
  copayment, coinsurance, or other cost-sharing obligation to cover
  the additional cost of obtaining a prescription drug through that
  method rather than by mail order.
         (c)  The board of trustees or a health benefit plan may not
  require a participant who obtains a multiple-month supply of a
  prescription drug from a retail pharmacy under Section 1560.003 to
  pay a deductible, copayment, coinsurance, or other cost-sharing
  obligation that differs from the amount the participant pays for a
  multiple-month supply of that drug through a mail order program.
         SECTION 3.  The change in law made by this Act applies only
  to a health benefit plan that is delivered, issued for delivery, or
  renewed on or after January 1, 2010. A health benefit plan that is
  delivered, issued for delivery, or renewed before January 1, 2010,
  is covered by the law in effect at the time the policy was
  delivered, issued for delivery, or renewed, and that law is
  continued in effect for that purpose.
         SECTION 4.  This Act takes effect September 1, 2009.