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A BILL TO BE ENTITLED
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AN ACT
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relating to pharmacy benefit managers contracting with the child |
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health plan program, the Medicaid managed care program, and health |
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plans for certain government employees. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Chapter 531, Government Code, is amended by |
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adding Subchapter Y to read as follows: |
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SUBCHAPTER Y. PHARMACY BENEFIT MANAGERS |
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Sec. 531.990. APPLICABILITY. This subchapter applies only |
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to a Medicaid managed care program under Chapter 533 and the child |
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health plan program. |
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Sec. 531.991. TRANSPARENCY IN PHARMACY BENEFIT MANAGEMENT. |
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(a) In this section, "maximum allowable cost" means a maximum |
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reimbursement amount for a group of therapeutically and |
|
pharmaceutically equivalent multiple source medications. |
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(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 |
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(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 |
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health plan program or Medicaid managed care program; |
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(2) develop and maintain a public Internet website and |
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post and maintain on the website the information required by |
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Subdivision (1)(C); |
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(3) notify each retail pharmacy affected by a |
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modification of a maximum allowable cost of the modification on the |
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date of the modification; |
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(4) disclose the data sources from which the pharmacy |
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benefit manager obtains pricing data used in establishing a maximum |
|
allowable cost; and |
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(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, |
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deletion, or addition. |
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(c) A contract to provide pharmacy benefit manager services |
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must require the pharmacy benefit manager to provide to the |
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commission the information described by Subsections (b)(1)(B) and |
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(C). On request, the commission shall provide the information to a |
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pharmacist or pharmacy. |
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(d) A contract to provide pharmacy benefit manager services |
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must require that each medication on a maximum allowable cost list: |
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(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. |
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(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; |
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(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; |
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(4) if the challenge is denied, provide each reason |
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for the denial; and |
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(5) report every 90 days to the commission the total |
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number of challenges made and denied in the preceding 90-day period |
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to the maximum allowable cost for each medication the maximum |
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allowable cost of which was challenged during that period. |
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SECTION 2. Subchapter B, Chapter 1551, Insurance Code, is |
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amended by adding Section 1551.0671 to read as follows: |
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Sec. 1551.0671. TRANSPARENCY IN PHARMACY BENEFIT |
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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 |
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trustees the information described by Subsections (b)(1)(B) and |
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(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 |
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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 |
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amended by adding Section 1575.111 to read as follows: |
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Sec. 1575.111. TRANSPARENCY IN PHARMACY BENEFIT |
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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. |
|
SECTION 4. Subchapter B, Chapter 1579, Insurance Code, is |
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amended by adding Section 1579.058 to read as follows: |
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Sec. 1579.058. TRANSPARENCY IN PHARMACY BENEFIT |
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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. |
|
SECTION 5. Subchapter B, Chapter 1601, Insurance Code, is |
|
amended by adding Section 1601.065 to read as follows: |
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Sec. 1601.065. TRANSPARENCY IN PHARMACY BENEFIT |
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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. |
|
SECTION 6. Subchapter Y, Chapter 531, Government Code, and |
|
Sections 1551.0671, 1575.111, 1579.058, and 1601.065, Insurance |
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Code, as added by this Act, apply only to a contract with a pharmacy |
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benefit manager entered into or renewed on or after the effective |
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date of this Act. |
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SECTION 7. This Act takes effect September 1, 2013. |