| |
|
|
A BILL TO BE ENTITLED
|
|
|
AN ACT
|
| |
|
|
relating to the contractual relationship between a pharmacist or |
|
|
pharmacy and a health benefit plan issuer or pharmacy benefit |
|
|
manager. |
|
|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|
|
SECTION 1. Chapter 1369, Insurance Code, is amended by |
|
|
adding Subchapter L to read as follows: |
|
|
SUBCHAPTER L. CONTRACTS WITH PHARMACISTS AND PHARMACIES |
|
|
Sec. 1369.551. DEFINITIONS. In this subchapter: |
|
|
(1) "Pharmacy benefit manager" has the meaning |
|
|
assigned by Section 4151.151. |
|
|
(2) "Pharmacy benefit network" means a network of |
|
|
pharmacies that have contracted with a pharmacy benefit manager to |
|
|
provide pharmacist services to enrollees. |
|
|
(3) "Pharmacy services administrative organization" |
|
|
means an entity that contracts with a pharmacist or pharmacy to |
|
|
conduct on behalf of the pharmacist or pharmacy the pharmacist's or |
|
|
pharmacy's business with a third-party payor, including a pharmacy |
|
|
benefit manager, in connection with pharmacy benefits and to assist |
|
|
the pharmacist or pharmacy by providing administrative services, |
|
|
including negotiating, executing, and administering a contract |
|
|
with a third-party payor and communicating with the third-party |
|
|
payor in connection with a contract or pharmacy benefits. |
|
|
Sec. 1369.552. APPLICABILITY OF SUBCHAPTER. (a) This |
|
|
subchapter applies only to a health benefit plan that provides |
|
|
benefits for medical or surgical expenses incurred as a result of a |
|
|
health condition, accident, or sickness, 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 other law, this subchapter applies |
|
|
to: |
|
|
(1) a small employer health benefit plan subject to |
|
|
Chapter 1501, including coverage provided through a health group |
|
|
cooperative under Subchapter B of that chapter; |
|
|
(2) a standard health benefit plan issued under |
|
|
Chapter 1507; |
|
|
(3) health benefits provided by or through a church |
|
|
benefits board under Subchapter I, Chapter 22, Business |
|
|
Organizations Code; |
|
|
(4) group health coverage made available by a school |
|
|
district in accordance with Section 22.004, Education Code; |
|
|
(5) a regional or local health care program operated |
|
|
under Section 75.104, Health and Safety Code; and |
|
|
(6) a self-funded health benefit plan sponsored by a |
|
|
professional employer organization under Chapter 91, Labor Code. |
|
|
(c) This subchapter does not apply to an issuer or provider |
|
|
of health benefits under or a pharmacy benefit manager |
|
|
administering pharmacy benefits under a workers' compensation |
|
|
insurance policy or other form of providing medical benefits under |
|
|
Title 5, Labor Code. |
|
|
Sec. 1369.553. REDUCTION OF CERTAIN CLAIM PAYMENT AMOUNTS |
|
|
PROHIBITED. (a) A health benefit plan issuer or pharmacy benefit |
|
|
manager may not directly or indirectly reduce the amount of a claim |
|
|
payment to a pharmacist or pharmacy after adjudication of the claim |
|
|
through the use of an aggregated effective rate, quality assurance |
|
|
program, other direct or indirect remuneration fee, or otherwise, |
|
|
except in accordance with an audit performed under Subchapter F. |
|
|
(b) Nothing in this section prohibits a health benefit plan |
|
|
issuer or pharmacy benefit manager from increasing a claim payment |
|
|
amount after adjudication of the claim. |
|
|
Sec. 1369.554. REIMBURSEMENT OF AFFILIATED AND |
|
|
NONAFFILIATED PHARMACISTS AND PHARMACIES. (a) In this section: |
|
|
(1) "Affiliated pharmacist or pharmacy" means a |
|
|
pharmacist or pharmacy that directly, or indirectly through one or |
|
|
more intermediaries, controls or is controlled by, or is under |
|
|
common control with, a pharmacy benefit manager. |
|
|
(2) "Nonaffiliated pharmacist or pharmacy" means a |
|
|
pharmacist or pharmacy that does not directly, or indirectly |
|
|
through one or more intermediaries, control and is not controlled |
|
|
by or under common control with a pharmacy benefit manager. |
|
|
(b) A pharmacy benefit manager may not pay an affiliated |
|
|
pharmacist or pharmacy a reimbursement amount that is more than the |
|
|
amount the pharmacy benefit manager pays a nonaffiliated pharmacist |
|
|
or pharmacy for the same pharmacist service. |
|
|
Sec. 1369.555. NETWORK CONTRACT FEE SCHEDULE. A pharmacy |
|
|
benefit network contract must specify or reference a separate fee |
|
|
schedule. Unless otherwise available in the contract, the fee |
|
|
schedule must be provided electronically in an easily accessible |
|
|
and complete spreadsheet format and, on request, in writing to each |
|
|
contracted pharmacist and pharmacy. The fee schedule must |
|
|
describe: |
|
|
(1) specific services or procedures that the |
|
|
pharmacist or pharmacy may deliver and the amount of the |
|
|
corresponding payment; |
|
|
(2) a methodology for calculating the amount of the |
|
|
payment based on a published fee schedule; or |
|
|
(3) any other reasonable manner that provides an |
|
|
ascertainable amount for payment for services. |
|
|
Sec. 1369.556. DISCLOSURE OF PHARMACY SERVICES |
|
|
ADMINISTRATIVE ORGANIZATION CONTRACT. A pharmacist or pharmacy |
|
|
that is a member of a pharmacy services administrative organization |
|
|
that enters into a contract with a health benefit plan issuer or |
|
|
pharmacy benefit manager on the pharmacist's or pharmacy's behalf |
|
|
is entitled to receive from the pharmacy services administrative |
|
|
organization a copy of the contract provisions applicable to the |
|
|
pharmacist or pharmacy, including each provision relating to the |
|
|
pharmacist's or pharmacy's rights and obligations under the |
|
|
contract. |
|
|
Sec. 1369.557. DELIVERY OF DRUGS. (a) Except in a case in |
|
|
which the health benefit plan issuer or pharmacy benefit manager |
|
|
makes a credible allegation of fraud against the pharmacist or |
|
|
pharmacy and provides reasonable notice of the allegation and the |
|
|
basis of the allegation to the pharmacist or pharmacy, a health |
|
|
benefit plan issuer or pharmacy benefit manager may not as a |
|
|
condition of a contract with a pharmacist or pharmacy prohibit the |
|
|
pharmacist or pharmacy from: |
|
|
(1) mailing or delivering a drug to a patient on the |
|
|
patient's request, to the extent permitted by law; or |
|
|
(2) charging a shipping and handling fee to a patient |
|
|
requesting a prescription be mailed or delivered if the pharmacist |
|
|
or pharmacy discloses to the patient before the delivery: |
|
|
(A) the fee that will be charged; and |
|
|
(B) that the fee may not be reimbursable by the |
|
|
health benefit plan issuer or pharmacy benefit manager. |
|
|
(b) A pharmacist or pharmacy may not charge a health benefit |
|
|
plan issuer or pharmacy benefit manager for the delivery of a |
|
|
prescription drug as described by this section unless the charge is |
|
|
specifically agreed to by the health benefit plan issuer or |
|
|
pharmacy benefit manager. |
|
|
Sec. 1369.558. PROFESSIONAL STANDARDS AND SCOPE OF PRACTICE |
|
|
REQUIREMENTS. A health benefit plan issuer or pharmacy benefit |
|
|
manager may not as a condition of a contract with a pharmacist or |
|
|
pharmacy: |
|
|
(1) require pharmacist or pharmacy accreditation |
|
|
standards or recertification requirements inconsistent with, more |
|
|
stringent than, or in addition to federal and state requirements; |
|
|
or |
|
|
(2) prohibit a licensed pharmacist or pharmacy from |
|
|
dispensing any drug that may be dispensed under the pharmacist's or |
|
|
pharmacy's license unless: |
|
|
(A) applicable state or federal law prohibits the |
|
|
pharmacist or pharmacy from dispensing the drug; or |
|
|
(B) the manufacturer of the drug requires that a |
|
|
pharmacist or pharmacy possess one or more accreditations or |
|
|
certifications to dispense the drug and the pharmacist or pharmacy |
|
|
does not meet the requirement. |
|
|
Sec. 1369.559. RETALIATION PROHIBITED. (a) A pharmacy |
|
|
benefit manager may not retaliate against a pharmacist or pharmacy |
|
|
based on the pharmacist's or pharmacy's exercise of any right or |
|
|
remedy under this chapter. Retaliation prohibited by this section |
|
|
includes: |
|
|
(1) terminating or refusing to renew a contract with |
|
|
the pharmacist or pharmacy; |
|
|
(2) subjecting the pharmacist or pharmacy to increased |
|
|
audits; or |
|
|
(3) failing to promptly pay the pharmacist or pharmacy |
|
|
any money owed by the pharmacy benefit manager to the pharmacist or |
|
|
pharmacy. |
|
|
(b) For purposes of this section, a pharmacy benefit manager |
|
|
is not considered to have retaliated against a pharmacist or |
|
|
pharmacy if the pharmacy benefit manager: |
|
|
(1) takes an action in response to a credible |
|
|
allegation of fraud against the pharmacist or pharmacy; and |
|
|
(2) provides reasonable notice to the pharmacist or |
|
|
pharmacy of the allegation of fraud and the basis of the allegation |
|
|
before taking the action. |
|
|
Sec. 1369.560. WAIVER PROHIBITED. The provisions of this |
|
|
subchapter may not be waived, voided, or nullified by contract. |
|
|
SECTION 2. The change in law made by this Act applies only |
|
|
to a contract entered into or renewed on or after the effective date |
|
|
of this Act. A contract entered into or renewed before the |
|
|
effective date of this Act 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 3. This Act takes effect September 1, 2021. |
|
|
|
|
|
* * * * * |