84R1613 PMO-F
 
  By: Schwertner S.B. No. 322
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to access to pharmacists, pharmacies, and pharmaceutical
  care under certain health benefit plans.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Chapter 1451, Insurance Code, is amended by
  adding Subchapter K to read as follows:
  SUBCHAPTER K. ACCESS TO PHARMACIES, PHARMACISTS, AND
  PHARMACEUTICAL CARE
         Sec. 1451.501.  DEFINITIONS. In this subchapter:
               (1)  "Drug," "pharmaceutical care," "pharmacist,"
  "pharmacy," and "prescription drug" have the meanings assigned by
  Section 551.003, Occupations Code.
               (2)  "Enrollee" means an individual who is covered
  under a health benefit plan, including a covered dependent.
               (3)  "Pharmacy benefit manager" has the meaning
  assigned by Section 4151.151.
         Sec. 1451.502.  APPLICABILITY OF SUBCHAPTER. (a) Except as
  provided by Section 1451.503, this subchapter applies only to a
  health benefit plan that provides benefits for medical, surgical,
  or other treatment expenses incurred as a result of a health
  condition, an accident, sickness, or substance abuse, 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 by:
               (1)  an insurance company;
               (2)  a group hospital service corporation operating
  under Chapter 842;
               (3)  a health maintenance organization operating under
  Chapter 843;
               (4)  an approved nonprofit health corporation that
  holds a certificate of authority under Chapter 844;
               (5)  a multiple employer welfare arrangement that holds
  a certificate of authority under Chapter 846;
               (6)  a stipulated premium company operating under
  Chapter 884;
               (7)  a fraternal benefit society operating under
  Chapter 885;
               (8)  a Lloyd's plan operating under Chapter 941; or
               (9)  an exchange operating under Chapter 942.
         (b)  Notwithstanding any provision in Chapter 1551, 1575,
  1579, or 1601 or any other law, this chapter applies to health
  benefit plan coverage provided under:
               (1)  Chapter 1551;
               (2)  Chapter 1575;
               (3)  Chapter 1579; and
               (4)  Chapter 1601.
         (c)  Notwithstanding Section 1501.251 or any other law, this
  chapter applies to coverage under a small employer health benefit
  plan subject to Chapter 1501.
         Sec. 1451.503.  EXCEPTION TO APPLICABILITY OF SUBCHAPTER.
  This subchapter does not apply to a self-insured, self-funded, or
  other employee welfare benefit plan that is exempt from state
  regulation under the Employee Retirement Income Security Act of
  1974 (29 U.S.C. Section 1001 et seq.).
         Sec. 1451.504.  SELECTION OF PHARMACIST AND PHARMACY.  A
  health benefit plan issuer or a pharmacy benefit manager
  administering pharmacy benefits under a health benefit plan may
  not:
               (1)  prohibit or limit an enrollee from selecting a
  pharmacist or pharmacy of the enrollee's choice to furnish
  prescription drugs or pharmaceutical care covered by the health
  benefit plan; or
               (2)  interfere with an enrollee's selection of a
  pharmacist or pharmacy to furnish prescription drugs or
  pharmaceutical care covered by the health benefit plan.
         Sec. 1451.505.  PARTICIPATION OF PHARMACISTS AND
  PHARMACIES. (a) Subject to Subsection (b), a health benefit plan
  issuer or a pharmacy benefit manager administering pharmacy
  benefits under a health benefit plan may not deny a pharmacist or
  pharmacy the right to participate as a provider or preferred
  provider, as applicable, under the health benefit plan if the
  pharmacist or pharmacy agrees to:
               (1)  provide prescription drugs and pharmaceutical
  care in accordance with the terms of the health benefit plan; and
               (2)  accept the administrative, financial, and
  professional conditions that apply to pharmacists and pharmacies
  who have been designated by the health benefit plan or the pharmacy
  benefit manager as providers or preferred providers, as applicable,
  under the health benefit plan.
         (b)  The conditions described by Subsection (a)(2) must be
  applied uniformly to all pharmacists and pharmacies who have been
  designated by the health benefit plan or the pharmacy benefit
  manager as providers or preferred providers, as applicable, under
  the health benefit plan.
         Sec. 1451.506.  MANDATORY PARTICIPATION PROHIBITED. A
  health benefit plan issuer or a pharmacy benefit manager
  administering pharmacy benefits under a health benefit plan may not
  require a pharmacist or pharmacy to participate as a provider or
  preferred provider under a health benefit plan as a condition of
  participating as a provider or preferred provider under another
  health benefit plan.
         Sec. 1451.507.  DOSAGE AND QUANTITY REQUIREMENTS. (a) A
  health benefit plan issuer or a pharmacy benefit manager
  administering pharmacy benefits under a health benefit plan may not
  require an enrollee to obtain or request a specific quantity or
  dosage supply of prescription drugs.
         (b)  Notwithstanding Subsection (a), an enrollee's physician
  or other prescribing health care provider may prescribe
  prescription drugs in a quantity or dosage supply the physician or
  provider determines appropriate and that is in compliance with
  state and federal statutes.
         Sec. 1451.508.  COST SAVING MEASURES ALLOWED. (a) Subject
  to Subsection (b), this subchapter does not prohibit a health
  benefit plan issuer or pharmacy benefit manager administering
  pharmacy benefits under a health benefit plan from, in an effort to
  achieve cost savings to the health benefit plan or the enrollee:
               (1)  limiting the quantity or dosage supply of a drug
  covered under the plan; or
               (2)  providing a financial incentive to encourage an
  enrollee or physician or other prescribing health care provider to
  use certain drugs in certain quantities.
         (b)  The quantity or dosage limitations and the financial
  incentives described by Subsection (a) must be applied or provided
  uniformly to all pharmacists and pharmacies who have been
  designated by the health benefit plan or pharmacy benefit manager
  as providers or preferred providers, as applicable, under the
  health benefit plan.
         Sec. 1451.509.  PHARMACY BENEFIT CARD PROGRAM. This
  subchapter does not prohibit a health benefit plan issuer or
  pharmacy benefit manager administering pharmacy benefits under a
  health benefit plan from establishing or administering a pharmacy
  benefit card program that is a "discount health care program" for
  purposes of Chapter 562 that authorizes an enrollee to obtain
  prescription drugs and pharmaceutical care from designated
  providers.
         Sec. 1451.510.  APPLICATION AND RENEWAL FEES. This
  subchapter does not prohibit a health benefit plan issuer or
  pharmacy benefit manager administering pharmacy benefits under a
  health benefit plan from establishing reasonable and uniform
  application and renewal fees for a pharmacist or pharmacy to
  participate as a provider or preferred provider, as applicable,
  under the health benefit plan.
         Sec. 1451.511.  COVERAGE NOT REQUIRED. This subchapter does
  not require a health benefit plan to provide coverage for drugs or
  pharmaceutical care.
         Sec. 1451.512.  CONFLICTING CONTRACT PROVISION VOID. A
  provision of a health benefit plan or of a contract with a pharmacy
  benefit manager that conflicts with this subchapter is void to the
  extent of the conflict.
         Sec. 1451.513.  INJUNCTIVE RELIEF. A pharmacist, pharmacy,
  or enrollee adversely affected by a violation of this subchapter
  may bring suit in district court for injunctive relief to enforce
  this subchapter.
         Sec. 1451.514.  DEPARTMENT MONITORING. The commissioner
  shall monitor health benefit plans and pharmacy benefit managers to
  ensure compliance with this subchapter.
         SECTION 2.  Section 843.303(b), Insurance Code, is amended
  to read as follows:
         (b)  Unless otherwise limited by Subchapter K, Chapter 1451
  [Article 21.52B], this section does not prohibit a health
  maintenance organization from rejecting an initial application
  from a physician or provider based on the determination that the
  plan has sufficient qualified physicians or providers.
         SECTION 3.  Section 843.304(c), Insurance Code, is amended
  to read as follows:
         (c)  This section does not require that a health maintenance
  organization:
               (1)  use a particular type of provider in its
  operation;
               (2)  accept each provider of a category or type, except
  as provided by Subchapter K, Chapter 1451 [Article 21.52B]; or
               (3)  contract directly with providers of a particular
  category or type.
         SECTION 4.  Article 21.52B, Insurance Code, is repealed.
         SECTION 5.  This Act applies only to a health benefit plan
  that is delivered, issued for delivery, or renewed on or after
  January 1, 2016. A health benefit plan delivered, issued for
  delivery, or renewed before January 1, 2016, is governed by the law
  as it existed immediately before the effective date of this Act, and
  that law is continued in effect for that purpose.
         SECTION 6.  This Act takes effect September 1, 2015.