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A BILL TO BE ENTITLED
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AN ACT
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relating to the contractual relationship between a pharmacist or |
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pharmacy and a health benefit plan issuer or pharmacy benefit |
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manager. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Chapter 1369, Insurance Code, is amended by |
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adding Subchapter K to read as follows: |
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SUBCHAPTER K. CONTRACTS WITH PHARMACISTS AND PHARMACIES |
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Sec. 1369.501. DEFINITIONS. In this subchapter: |
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(1) "Pharmacy benefit manager" means a person, other |
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than a pharmacist or pharmacy, who acts as an administrator in |
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connection with pharmacy benefits. |
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(2) "Pharmacy services administrative organization" |
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means an entity that contracts with a pharmacist or pharmacy to |
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conduct on behalf of the pharmacist or pharmacy the pharmacist's or |
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pharmacy's business with a third-party payor, including a pharmacy |
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benefit manager, in connection with pharmacy benefits and to assist |
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the pharmacist or pharmacy by providing administrative services, |
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including negotiating, executing, and administering a contract |
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with a third-party payor and communicating with the third-party |
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payor in connection with a contract or pharmacy benefits. |
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Sec. 1369.502. APPLICABILITY OF SUBCHAPTER. (a) This |
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subchapter applies only to a health benefit plan that provides |
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benefits for medical or surgical expenses incurred as a result of a |
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health condition, accident, or sickness, including an individual, |
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group, blanket, or franchise insurance policy or insurance |
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agreement, a group hospital service contract, or an individual or |
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group evidence of coverage or similar coverage document that is |
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offered by: |
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(1) an insurance company; |
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(2) a group hospital service corporation operating |
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under Chapter 842; |
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(3) a health maintenance organization operating under |
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Chapter 843; |
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(4) an approved nonprofit health corporation that |
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holds a certificate of authority under Chapter 844; |
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(5) a multiple employer welfare arrangement that holds |
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a certificate of authority under Chapter 846; |
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(6) a stipulated premium company operating under |
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Chapter 884; |
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(7) a fraternal benefit society operating under |
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Chapter 885; |
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(8) a Lloyd's plan operating under Chapter 941; or |
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(9) an exchange operating under Chapter 942. |
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(b) Notwithstanding any other law, this chapter applies to: |
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(1) a small employer health benefit plan subject to |
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Chapter 1501, including coverage provided through a health group |
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cooperative under Subchapter B of that chapter; |
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(2) a standard health benefit plan issued under |
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Chapter 1507; |
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(3) health benefits provided by or through a church |
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benefits board under Subchapter I, Chapter 22, Business |
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Organizations Code; |
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(4) group health coverage made available by a school |
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district in accordance with Section 22.004, Education Code; |
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(5) a regional or local health care program operated |
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under Section 75.104, Health and Safety Code; |
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(6) a self-funded health benefit plan sponsored by a |
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professional employer organization under Chapter 91, Labor Code; |
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(7) county employee group health benefits provided |
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under Chapter 157, Local Government Code; and |
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(8) health and accident coverage provided by a risk |
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pool created under Chapter 172, Local Government Code. |
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Sec. 1369.503. PERFORMANCE MEASURES AND RELATED FEES. (a) |
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A health benefit plan issuer or pharmacy benefit manager that |
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establishes a contractual pharmacy performance measure or pay for |
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performance pharmacy network shall evaluate the performance of |
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pharmacists or pharmacies for purposes of that measure or network |
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using a nationally recognized performance information management |
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tool that provides standardized, benchmarked data to improve |
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pharmacy performance. |
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(b) A health benefit plan issuer or pharmacy benefit manager |
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may not directly or indirectly charge or hold a pharmacist or |
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pharmacy responsible for a fee if: |
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(1) the pharmacist or pharmacy uses the performance |
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information management tool described by Subsection (a) to produce |
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a score or metric for patient care; and |
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(2) the score or metric is within the criteria |
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identified by the health benefit plan issuer or pharmacy benefit |
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manager using the data provided by the performance information |
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management tool. |
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(c) If a health benefit plan issuer or pharmacy benefit |
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manager imposes a fee on a pharmacist or pharmacy based on a score |
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or metric produced by the performance information management tool |
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described by Subsection (a), the health benefit plan issuer or |
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pharmacy benefit manager: |
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(1) may recover the fee as an offset against the |
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professional dispensing fee owed under the contract with the |
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pharmacist or pharmacy; and |
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(2) may not recover the fee as an offset against any |
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other amount owed to the pharmacist or pharmacy under the contract. |
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Sec. 1369.504. DISCLOSURE OF PHARMACY SERVICES |
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ADMINISTRATIVE ORGANIZATION CONTRACT. A pharmacist or pharmacy |
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that is a member of a pharmacy services administrative organization |
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that enters into a contract with a health benefit plan issuer or |
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pharmacy benefit manager on the pharmacist's or pharmacy's behalf |
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is entitled to receive a copy of the contract. |
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Sec. 1369.505. DELIVERY OF DRUGS. A health benefit plan |
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issuer or pharmacy benefit manager may not as a condition of a |
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contract with a pharmacist or pharmacy prohibit the pharmacist or |
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pharmacy from: |
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(1) mailing or delivering drugs to a patient as an |
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ancillary service of the pharmacist or pharmacy as otherwise |
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allowed by law; or |
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(2) charging a shipping and handling fee to a patient |
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requesting a prescription be mailed or delivered. |
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Sec. 1369.506. PROFESSIONAL STANDARDS AND SCOPE OF PRACTICE |
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REQUIREMENTS. A health benefit plan issuer or pharmacy benefit |
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manager may not as a condition of a contract with a pharmacist or |
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pharmacy: |
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(1) require pharmacist or pharmacy accreditation |
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standards or recertification requirements inconsistent with, more |
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stringent than, or in addition to federal and state requirements |
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for licensure as a pharmacist or pharmacy in this state; or |
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(2) prohibit a licensed pharmacist or pharmacy from |
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dispensing any drug that may be dispensed under the pharmacist's or |
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pharmacy's license. |
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Sec. 1369.507. WAIVER PROHIBITED. The provisions of this |
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subchapter may not be waived, voided, or nullified by contract. |
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Sec. 1369.508. UNFAIR OR DECEPTIVE ACT OR PRACTICE. A |
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violation of this subchapter by a health benefit plan issuer or |
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pharmacy benefit manager is an unfair or deceptive act or practice |
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in the business of insurance under Chapter 541. |
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SECTION 2. The change in law made by this Act applies only |
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to a contract entered into or renewed on or after the effective date |
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of this Act. A contract entered into or renewed before the |
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effective date of this Act is governed by the law as it existed |
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immediately before the effective date of this Act, and that law is |
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continued in effect for that purpose. |
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SECTION 3. This Act takes effect September 1, 2019. |