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A BILL TO BE ENTITLED
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AN ACT
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relating to pharmacy benefit networks and pharmacy benefit |
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managers. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 1458.001, Insurance Code, is amended by |
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amending Subdivisions (2), (7), and (8) and adding Subdivision |
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(3-a) to read as follows: |
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(2) "Contracting entity" means a person who: |
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(A) enters into a direct contract with a provider |
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for the delivery of health care services or drugs to covered |
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individuals; and |
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(B) in the ordinary course of business |
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establishes a provider network or networks for access by another |
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party. |
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(3-a) "Drug" has the meaning assigned by Section |
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551.003, Occupations Code. |
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(7)(A) "Provider" means: |
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(i) an advanced practice nurse; |
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(ii) an optometrist; |
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(iii) a therapeutic optometrist; |
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(iv) a physician; |
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(v) a physician assistant; |
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(vi) a professional association composed |
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solely of physicians, optometrists, or therapeutic optometrists; |
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(vii) a single legal entity authorized to |
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practice medicine owned by two or more physicians; |
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(viii) a nonprofit health corporation |
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certified by the Texas Medical Board under Chapter 162, Occupations |
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Code; |
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(ix) a partnership composed solely of |
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physicians, optometrists, or therapeutic optometrists; |
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(x) a physician-hospital organization that |
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acts exclusively as an administrator for a provider to facilitate |
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the provider's participation in health care contracts; [or] |
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(xi) an institution that is licensed under |
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Chapter 241, Health and Safety Code; or |
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(xii) a pharmacist or pharmacy. |
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(B) "Provider" does not include a |
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physician-hospital organization that leases or rents the |
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physician-hospital organization's network to another party. |
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(8) "Provider network contract" means a contract |
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between a contracting entity and a provider for the delivery of, and |
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payment for, health care services or drugs to a covered individual. |
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SECTION 2. Section 1458.002(a), Insurance Code, is amended |
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to read as follows: |
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(a) In this chapter, "health benefit plan" means: |
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(1) a hospital and medical expense incurred policy; |
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(2) a nonprofit health care service plan contract; |
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(3) a health maintenance organization subscriber |
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contract; or |
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(4) any other health care plan or arrangement that |
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pays for or furnishes medical or health care services or drugs. |
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SECTION 3. Sections 1458.101(c), (d), and (e), Insurance |
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Code, are amended to read as follows: |
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(c) A contracting entity may not provide a person access to |
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health care services, drugs, or contractual discounts under a |
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provider network contract unless the provider network contract |
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specifically states that the contracting entity may contract with a |
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person to provide access to the contracting entity's rights and |
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responsibilities under the provider network contract. |
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(d) The provider network contract must require that on the |
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request of the provider, the contracting entity will provide |
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information necessary to determine whether a particular person has |
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been authorized to access the provider's health care services, |
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drugs, and contractual discounts. |
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(e) To be enforceable against a provider, a provider network |
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contract, including the lines of business described by Subsections |
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(a) and (f), must also specify or reference a separate fee schedule |
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for each such line of business. The separate fee schedule may |
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describe specific services or procedures or drugs that the provider |
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will deliver along with a corresponding payment, may describe a |
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methodology for calculating payment based on a published fee |
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schedule, or may describe payment in any other reasonable manner |
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that specifies a definite payment for services or drugs. The fee |
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information may be provided by any reasonable method, including |
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electronically. |
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SECTION 4. Section 1458.102(a), Insurance Code, is amended |
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to read as follows: |
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(a) A contracting entity may not provide a person access to |
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health care services, drugs, or contractual discounts under a |
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provider network contract unless the provider network contract |
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specifically states that the person must comply with all applicable |
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terms, limitations, and conditions of the provider network |
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contract. |
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SECTION 5. Section 4151.001, Insurance Code, is amended by |
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adding Subdivisions (3-a) and (5-a) to read as follows: |
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(3-a) "Pharmacy benefit management" means the |
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administration or management of prescription drug benefits, |
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including: |
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(A) retail pharmacy network management; |
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(B) pharmacy discount card management; |
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(C) claims payment to a retail pharmacy for |
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prescription medications dispensed to plan participants; |
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(D) clinical formulary development and |
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management services, including utilization management and quality |
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assurance programs; |
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(E) rebate contracting and administration; |
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(F) auditing contracted pharmacies; |
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(G) establishing pharmacy reimbursement pricing |
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and methodologies; and |
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(H) determining single and multiple source |
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medications. |
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(5-a) "Retail pharmacy" means a pharmacy licensed |
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under Chapter 560, Occupations Code, that dispenses medications to |
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the public, including an independent pharmacy, a chain pharmacy, a |
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supermarket pharmacy, or a mass merchandiser pharmacy. The term |
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does not include a pharmacy that dispenses prescription medications |
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primarily through the mail, a nursing home pharmacy, a long-term |
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care facility pharmacy, a hospital pharmacy, a clinic pharmacy, a |
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charitable or nonprofit pharmacy, a government pharmacy, or a |
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pharmacy benefit manager that is serving in its capacity as a |
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pharmacy benefit manager. |
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SECTION 6. Section 4151.151, Insurance Code, is amended to |
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read as follows: |
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Sec. 4151.151. DEFINITION. In this subchapter, "pharmacy |
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benefit manager" means a person, other than a pharmacy or |
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pharmacist, who acts as an administrator that provides pharmacy |
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benefit management in connection with pharmacy benefits. |
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SECTION 7. Chapter 1458, Insurance Code, as amended by this |
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Act, applies only to a provider network contract entered into or |
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renewed on or after January 1, 2018. A provider network contract |
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entered into or renewed before January 1, 2018, is governed by the |
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law as it existed immediately before the effective date of this Act, |
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and that law is continued in effect for that purpose. |
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SECTION 8. This Act takes effect September 1, 2017. |