INTRODUCED
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HOUSE COMMITTEE
SUBSTITUTE
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SECTION 1. Chapter 531,
Government Code, is amended by adding Subchapter Y to read as follows:
SUBCHAPTER Y. PHARMACY
BENEFIT MANAGERS
Sec. 531.990.
APPLICABILITY.
Sec. 531.991.
TRANSPARENCY IN PHARMACY BENEFIT MANAGEMENT. (a) In this section,
"maximum allowable cost" means a maximum reimbursement amount for
a group of therapeutically and pharmaceutically equivalent multiple source
medications.
(b) A contract to provide pharmacy benefit
manager services must require the pharmacy benefit manager to:
(1) establish:
(A) a method of
calculating, updating, and revising a maximum allowable cost for each
covered medication;
(B) a frequency for updating or revising the
maximum allowable cost; and
(C) a maximum allowable
cost list that uniformly serves as a basis for the calculation of
reimbursement amounts for pharmacy claims covered by the child health plan
program or Medicaid managed care program; and
(2) develop and maintain
a public Internet website and post and maintain on the website the
information required by Subdivision (1).
(c) A contract to provide
pharmacy benefit manager services must require the pharmacy benefit manager
to provide to the commission the information required
by Subsection (b)(1). On request, the commission shall provide the
information to a pharmacist or pharmacy.
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SECTION 1. Chapter 531,
Government Code, is amended by adding Subchapter Y to read as follows:
SUBCHAPTER Y. PHARMACY
BENEFIT MANAGERS
Sec. 531.990.
APPLICABILITY.
Sec. 531.991.
TRANSPARENCY IN PHARMACY BENEFIT MANAGEMENT. (a) In this section,
"maximum allowable cost" means a maximum reimbursement amount for
a group of therapeutically and pharmaceutically equivalent multiple source
medications.
(b) Each contract to provide pharmacy benefit
manager services must require the pharmacy benefit manager to:
(1) establish:
(A) a method of
calculating, updating, and revising a maximum allowable cost for each covered
medication;
(B) intervals not to exceed seven days for
updating or revising the maximum allowable cost for each medication on the maximum allowable cost list; and
(C) for that contract a single maximum allowable
cost list that uniformly serves as a basis for the calculation of
reimbursement amounts for pharmacy claims covered by the child health plan
program or Medicaid managed care program;
(2) develop and maintain
a public Internet website and post and maintain on the website the
information required by Subdivision (1)(C);
(3) notify each retail pharmacy affected by a modification of a
maximum allowable cost of the modification on the date of the modification;
(4) disclose the data sources from which the pharmacy benefit
manager obtains pricing data used in establishing a maximum allowable cost;
and
(5) not less frequently than once a week, notify each retail
pharmacy affected by the pharmacy benefit manager's substitution or
deletion of, or addition to, a data source from which the pharmacy benefit
manager obtains pricing data used in establishing a maximum allowable cost
of the substitution, deletion, or addition.
(c) A contract to provide
pharmacy benefit manager services must require the pharmacy benefit manager
to provide to the commission the information described
by Subsections (b)(1)(B) and (C). On
request, the commission shall provide the information to a pharmacist or
pharmacy.
(d) A contract to provide pharmacy benefit manager services must
require that each medication on a maximum allowable cost list:
(1) is listed as "A" or "B" rated in the most
recent version of the United States Food and Drug Administration's Drug
Products with Therapeutic Equivalence Evaluations, also known as the Orange
Book;
(2) is rated "NR" or "NA" by Medi-Span; or
(3) has a similar rating by a nationally recognized reference.
(e) A contract to provide pharmacy benefit manager services must
require the pharmacy benefit manager to:
(1) provide a procedure for a retail pharmacy to challenge a listed
maximum allowable cost;
(2) respond to a challenge under that procedure not later than the
15th day after the date the challenge is made;
(3) if the challenge is successful, adjust the maximum allowable
cost effective on the date the challenge is resolved and apply the
adjustment to all retail pharmacies under the contract;
(4) if the challenge is denied, provide each reason for the denial;
and
(5) report every 90 days to the commission the total number of
challenges made and denied in the preceding 90-day period to the maximum
allowable cost for each medication the maximum allowable cost of which was
challenged during that period.
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SECTION 2. Subchapter B,
Chapter 1551, Insurance Code, is amended by adding Section 1551.0671 to
read as follows:
Sec. 1551.0671. TRANSPARENCY
IN PHARMACY BENEFIT MANAGEMENT. (a) In this section, "maximum
allowable cost" means a maximum reimbursement amount for a group of
therapeutically and pharmaceutically equivalent multiple source
medications.
(b) A contract to provide
pharmacy benefit manager services must require the pharmacy benefit manager
to:
(1) establish:
(A) a method of
calculating, updating, and revising a maximum allowable cost for each
covered medication;
(B) a frequency for updating or revising the
maximum allowable cost; and
(C) a maximum allowable
cost list that uniformly serves as a basis for the calculation of
reimbursement amounts for pharmacy claims covered by the group benefits
program; and
(2) develop and maintain
a public Internet website and post and maintain on the website the
information required by Subdivision (1).
(c) A contract to provide
pharmacy benefit manager services must require the pharmacy benefit manager
to provide to the board of trustees the information required by Subsection (b)(1). On request, the board of
trustees shall provide the information to a pharmacist or pharmacy.
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SECTION 2. Subchapter B,
Chapter 1551, Insurance Code, is amended by adding Section 1551.0671 to
read as follows:
Sec. 1551.0671.
TRANSPARENCY IN PHARMACY BENEFIT MANAGEMENT. (a) In this section,
"maximum allowable cost" means a maximum reimbursement amount for
a group of therapeutically and pharmaceutically equivalent multiple source
medications.
(b) Each contract to
provide pharmacy benefit manager services must require the pharmacy benefit
manager to:
(1) establish:
(A) a method of
calculating, updating, and revising a maximum allowable cost for each
covered medication;
(B) intervals not to exceed seven days for
updating or revising the maximum allowable cost for each medication on the maximum allowable cost list; and
(C) for that contract a single maximum allowable
cost list that uniformly serves as a basis for the calculation of
reimbursement amounts for pharmacy claims covered by the group benefits
program;
(2) develop and maintain
a public Internet website and post and maintain on the website the
information required by Subdivision (1)(C);
(3) notify each retail pharmacy affected by a modification of a
maximum allowable cost of the modification on the date of the modification;
(4) disclose the data sources from which the pharmacy benefit
manager obtains pricing data used in establishing a maximum allowable cost;
and
(5) not less frequently than once a week, notify each retail
pharmacy affected by the pharmacy benefit manager's substitution or
deletion of, or addition to, a data source from which the pharmacy benefit
manager obtains pricing data used in establishing a maximum allowable cost
of the substitution, deletion, or addition.
(c) A contract to provide
pharmacy benefit manager services must require the pharmacy benefit manager
to provide to the board of trustees the information described by Subsections (b)(1)(B)
and (C). On request, the board of trustees shall provide the information
to a pharmacist or pharmacy.
(d) A contract to provide pharmacy benefit manager services must
require that each medication on a maximum allowable cost list:
(1) is listed as "A" or "B" rated in the most
recent version of the United States Food and Drug Administration's Drug
Products with Therapeutic Equivalence Evaluations, also known as the Orange
Book;
(2) is rated "NR" or "NA" by Medi-Span; or
(3) has a similar rating by a nationally recognized reference.
(e) A contract to provide pharmacy benefit manager services must
require the pharmacy benefit manager to:
(1) provide a procedure for a retail pharmacy to challenge a listed
maximum allowable cost;
(2) respond to a challenge under that procedure not later than the
15th day after the date the challenge is made;
(3) if the challenge is successful, adjust the maximum allowable
cost effective on the date the challenge is resolved and apply the
adjustment to all retail pharmacies under the contract;
(4) if the challenge is denied, provide each reason for the denial;
and
(5) report every 90 days to the board of trustees the total number
of challenges made and denied in the preceding 90-day period to the maximum
allowable cost for each medication the maximum allowable cost of which was
challenged during that period.
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SECTION 3. Subchapter C,
Chapter 1575, Insurance Code, is amended by adding Section 1575.111 to read
as follows:
Sec. 1575.111.
TRANSPARENCY IN PHARMACY BENEFIT MANAGEMENT. (a) In this section,
"maximum allowable cost" means a maximum reimbursement amount for
a group of therapeutically and pharmaceutically equivalent multiple source
medications.
(b) A contract to provide
pharmacy benefit manager services must require the pharmacy benefit manager
to:
(1) establish:
(A) a method of calculating,
updating, and revising a maximum allowable cost for each covered
medication;
(B) a frequency for updating or revising a maximum allowable
cost; and
(C) a maximum allowable
cost list that uniformly serves as a basis for the calculation of reimbursement
amounts for pharmacy claims covered by the group program; and
(2) develop and maintain
a public Internet website and post and maintain on the website the
information required by Subdivision (1).
(c) A contract to provide
pharmacy benefit manager services must require the pharmacy benefit manager
to provide to the trustee the information required
by Subsection (b)(1). On request, the trustee shall provide the
information to a pharmacist or pharmacy.
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SECTION 3. Subchapter C,
Chapter 1575, Insurance Code, is amended by adding Section 1575.111 to read
as follows:
Sec. 1575.111.
TRANSPARENCY IN PHARMACY BENEFIT MANAGEMENT. (a) In this section,
"maximum allowable cost" means a maximum reimbursement amount for
a group of therapeutically and pharmaceutically equivalent multiple source
medications.
(b) Each contract to
provide pharmacy benefit manager services must require the pharmacy benefit
manager to:
(1) establish:
(A) a method of
calculating, updating, and revising a maximum allowable cost for each
covered medication;
(B) intervals not to exceed seven days for updating or revising
the maximum allowable cost for each
medication on the maximum allowable cost list; and
(C) for that contract a single maximum allowable
cost list that uniformly serves as a basis for the calculation of
reimbursement amounts for pharmacy claims covered by the group program;
(2) develop and maintain
a public Internet website and post and maintain on the website the
information required by Subdivision (1)(C);
(3) notify each retail pharmacy affected by a modification of a
maximum allowable cost of the modification on the date of the modification;
(4) disclose the data sources from which the pharmacy benefit
manager obtains pricing data used in establishing a maximum allowable cost;
and
(5) not less frequently than once a week, notify each retail
pharmacy affected by the pharmacy benefit manager's substitution or
deletion of, or addition to, a data source from which the pharmacy benefit
manager obtains pricing data used in establishing a maximum allowable cost
of the substitution, deletion, or addition.
(c) A contract to provide
pharmacy benefit manager services must require the pharmacy benefit manager
to provide to the trustee the information described
by Subsections (b)(1)(B) and (C). On
request, the trustee shall provide the information to a pharmacist or
pharmacy.
(d) A contract to provide pharmacy benefit manager services must
require that each medication on a maximum allowable cost list:
(1) is listed as "A" or "B" rated in the most
recent version of the United States Food and Drug Administration's Drug
Products with Therapeutic Equivalence Evaluations, also known as the Orange
Book;
(2) is rated "NR" or "NA" by Medi-Span; or
(3) has a similar rating by a nationally recognized reference.
(e) A contract to provide pharmacy benefit manager services must
require the pharmacy benefit manager to:
(1) provide a procedure for a retail pharmacy to challenge a listed
maximum allowable cost;
(2) respond to a challenge under that procedure not later than the
15th day after the date the challenge is made;
(3) if the challenge is successful, adjust the maximum allowable
cost effective on the date the challenge is resolved and apply the
adjustment to all retail pharmacies under the contract;
(4) if the challenge is denied, provide each reason for the denial;
and
(5) report every 90 days to the trustee the total number of
challenges made and denied in the preceding 90-day period to the maximum
allowable cost for each medication the maximum allowable cost of which was
challenged during that period.
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SECTION 4. Subchapter B,
Chapter 1579, Insurance Code, is amended by adding Section 1579.058 to read
as follows:
Sec. 1579.058.
TRANSPARENCY IN PHARMACY BENEFIT MANAGEMENT. (a) In this section,
"maximum allowable cost" means a maximum reimbursement amount for
a group of therapeutically and pharmaceutically equivalent multiple source
medications.
(b) A contract to provide
pharmacy benefit manager services must require the pharmacy benefit manager
to:
(1) establish:
(A) a method of
calculating, updating, and revising a maximum allowable cost for each
covered medication;
(B) a frequency for updating or revising a
maximum allowable cost; and
(C) a maximum allowable
cost list that uniformly serves as a basis for the calculation of
reimbursement amounts for pharmacy claims covered by a health coverage
plan; and
(2) develop and maintain
a public Internet website and post and maintain on the website the information
required by Subdivision (1).
(c) A contract to provide
pharmacy benefit manager services must require the pharmacy benefit manager
to provide to the trustee the information required
by Subsection (b)(1). On request, the trustee shall provide the
information to a pharmacist or pharmacy.
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SECTION 4. Subchapter B,
Chapter 1579, Insurance Code, is amended by adding Section 1579.058 to read
as follows:
Sec. 1579.058.
TRANSPARENCY IN PHARMACY BENEFIT MANAGEMENT. (a) In this section, "maximum
allowable cost" means a maximum reimbursement amount for a group of
therapeutically and pharmaceutically equivalent multiple source
medications.
(b) Each contract to
provide pharmacy benefit manager services must require the pharmacy benefit
manager to:
(1) establish:
(A) a method of
calculating, updating, and revising a maximum allowable cost for each
covered medication;
(B) intervals not to exceed seven days for
updating or revising the maximum allowable cost for each medication on the maximum allowable cost list; and
(C) for that contract a single maximum allowable
cost list that uniformly serves as a basis for the calculation of
reimbursement amounts for pharmacy claims covered by a health coverage
plan;
(2) develop and maintain
a public Internet website and post and maintain on the website the
information required by Subdivision (1)(C);
(3) notify each retail pharmacy affected by a modification of a
maximum allowable cost of the modification on the date of the modification;
(4) disclose the data sources from which the pharmacy benefit
manager obtains pricing data used in establishing a maximum allowable cost;
and
(5) not less frequently than once a week, notify each retail
pharmacy affected by the pharmacy benefit manager's substitution or
deletion of, or addition to, a data source from which the pharmacy benefit
manager obtains pricing data used in establishing a maximum allowable cost
of the substitution, deletion, or addition.
(c) A contract to provide
pharmacy benefit manager services must require the pharmacy benefit manager
to provide to the trustee the information described
by Subsections (b)(1)(B) and (C). On
request, the trustee shall provide the information to a pharmacist or
pharmacy.
(d) A contract to provide pharmacy benefit manager services must
require that each medication on a maximum allowable cost list:
(1) is listed as "A" or "B" rated in the most
recent version of the United States Food and Drug Administration's Drug
Products with Therapeutic Equivalence Evaluations, also known as the Orange
Book;
(2) is rated "NR" or "NA" by Medi-Span; or
(3) has a similar rating by a nationally recognized reference.
(e) A contract to provide pharmacy benefit manager services must
require the pharmacy benefit manager to:
(1) provide a procedure for a retail pharmacy to challenge a listed
maximum allowable cost;
(2) respond to a challenge under that procedure not later than the
15th day after the date the challenge is made;
(3) if the challenge is successful, adjust the maximum allowable
cost effective on the date the challenge is resolved and apply the
adjustment to all retail pharmacies under the contract;
(4) if the challenge is denied, provide each reason for the denial;
and
(5) report every 90 days to the trustee the total number of
challenges made and denied in the preceding 90-day period to the maximum
allowable cost for each medication the maximum allowable cost of which was
challenged during that period.
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SECTION 5. Subchapter B,
Chapter 1601, Insurance Code, is amended by adding Section 1601.065 to read
as follows:
Sec. 1601.065.
TRANSPARENCY IN PHARMACY BENEFIT MANAGEMENT. (a) In this section,
"maximum allowable cost" means a maximum reimbursement amount for
a group of therapeutically and pharmaceutically equivalent multiple source
medications.
(b) A contract to provide
pharmacy benefit manager services must require the pharmacy benefit manager
to:
(1) establish:
(A) a method of
calculating, updating, and revising the maximum allowable cost for each
covered medication;
(B) a frequency for updating or revising a
maximum allowable cost; and
(C) a maximum allowable
cost list that uniformly serves as a basis for the calculation of
reimbursement amounts for pharmacy claims covered by the basic coverage;
and
(2) develop and maintain
a public Internet website and post and maintain on the website the
information required by Subdivision (1).
(c) A contract to provide
pharmacy benefit manager services must require the pharmacy benefit manager
to provide to the governing board of the system the information required by Subsection (b)(1). On request,
the system shall provide the information to a pharmacist or pharmacy.
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SECTION 5. Subchapter B,
Chapter 1601, Insurance Code, is amended by adding Section 1601.065 to read
as follows:
Sec. 1601.065.
TRANSPARENCY IN PHARMACY BENEFIT MANAGEMENT. (a) In this section,
"maximum allowable cost" means a maximum reimbursement amount for
a group of therapeutically and pharmaceutically equivalent multiple source
medications.
(b) Each contract to
provide pharmacy benefit manager services must require the pharmacy benefit
manager to:
(1) establish:
(A) a method of
calculating, updating, and revising a maximum allowable cost for each
covered medication;
(B) intervals not to exceed seven days for
updating or revising the maximum allowable cost for each medication on the maximum allowable cost list; and
(C) for that contract a single maximum allowable
cost list that uniformly serves as a basis for the calculation of reimbursement
amounts for pharmacy claims covered by the basic coverage;
(2) develop and maintain
a public Internet website and post and maintain on the website the
information required by Subdivision (1)(C);
(3) notify each retail pharmacy affected by a modification of a
maximum allowable cost of the modification on the date of the modification;
(4) disclose the data sources from which the pharmacy benefit
manager obtains pricing data used in establishing a maximum allowable cost;
and
(5) not less frequently than once a week, notify each retail
pharmacy affected by the pharmacy benefit manager's substitution or
deletion of, or addition to, a data source from which the pharmacy benefit
manager obtains pricing data used in establishing a maximum allowable cost
of the substitution, deletion, or addition.
(c) A contract to provide
pharmacy benefit manager services must require the pharmacy benefit manager
to provide to the governing board of the system the information described by Subsections (b)(1)(B) and (C). On request, the system shall
provide the information to a pharmacist or pharmacy.
(d) A contract to provide pharmacy benefit manager services must
require that each medication on a maximum allowable cost list:
(1) is listed as "A" or "B" rated in the most
recent version of the United States Food and Drug Administration's Drug
Products with Therapeutic Equivalence Evaluations, also known as the Orange
Book;
(2) is rated "NR" or "NA" by Medi-Span; or
(3) has a similar rating by a nationally recognized reference.
(e) A contract to provide pharmacy benefit manager services must
require the pharmacy benefit manager to:
(1) provide a procedure for a retail pharmacy to challenge a listed
maximum allowable cost;
(2) respond to a challenge under that procedure not later than the
15th day after the date the challenge is made;
(3) if the challenge is successful, adjust the maximum allowable
cost effective on the date the challenge is resolved and apply the
adjustment to all retail pharmacies under the contract;
(4) if the challenge is denied, provide each reason for the denial;
and
(5) report every 90 days to the system the total number of
challenges made and denied in the preceding 90-day period to the maximum
allowable cost for each medication the maximum allowable cost of which was
challenged during that period.
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SECTION 6. Subchapter Y,
Chapter 531, Government Code, and Sections 1551.0671, 1575.111, 1579.058,
and 1601.065, Insurance Code, as added by this Act, apply only to a
contract with a pharmacy benefit manager executed
or renewed on or after the effective date of this Act.
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SECTION 6. Subchapter Y,
Chapter 531, Government Code, and Sections 1551.0671, 1575.111, 1579.058,
and 1601.065, Insurance Code, as added by this Act, apply only to a
contract with a pharmacy benefit manager entered
into or renewed on or after the effective date of this Act.
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SECTION 7. This Act takes
effect September 1, 2013.
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SECTION 7. Same as introduced
version.
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