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