By: Harris, et al. H.B. No. 1919
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to certain prohibited practices for certain health benefit
  plan issuers and certain required and prohibited practices for
  certain pharmacy benefit managers, including pharmacy benefit
  managers participating in the Medicaid and child health plan
  programs.
         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. AFFILIATED PROVIDERS
         Sec. 1369.551.  DEFINITIONS. In this subchapter:
               (1)  "Affiliated provider" means a pharmacy or durable
  medical equipment provider that directly, or indirectly through one
  or more intermediaries, controls, is controlled by, or is under
  common control with a health benefit plan issuer or pharmacy
  benefit manager.
               (2)  "Health benefit plan" has the meaning assigned by
  Section 1369.251.
               (3)  "Pharmacy benefit manager" has the meaning
  assigned by Section 4151.151.
         Sec. 1369.552.  TRANSFER OR ACCEPTANCE OF CERTAIN RECORDS
  PROHIBITED. (a) In this section, "commercial purpose" does not
  include pharmacy reimbursement, formulary compliance,
  pharmaceutical care, utilization review by a health care provider,
  or a public health activity authorized by law.
         (b)  A health benefit plan issuer or pharmacy benefit manager
  may not transfer to or receive from the issuer's or manager's
  affiliated provider a record containing patient- or
  prescriber-identifiable prescription information for a commercial
  purpose.
         Sec. 1369.553.  PROHIBITION ON CERTAIN COMMUNICATIONS. (a)
  A health benefit plan issuer or pharmacy benefit manager may not
  steer or direct a patient to use the issuer's or manager's
  affiliated provider through any oral or written communication,
  including:
               (1)  online messaging regarding the provider; or
               (2)  patient- or prospective patient-specific
  advertising, marketing, or promotion of the provider.
         (b)  This section does not prohibit a health benefit plan
  issuer or pharmacy benefit manager from including the issuer's or
  manager's affiliated provider in a patient or prospective patient
  communication, if the communication:
               (1)  is regarding information about the cost or service
  provided by pharmacies or durable medical equipment providers in
  the network of a health benefit plan in which the patient or
  prospective patient is enrolled; and
               (2)  includes accurate comparable information
  regarding pharmacies or durable medical equipment providers in the
  network that are not the issuer's or manager's affiliated
  providers.
         Sec. 1369.554.  PROHIBITION ON CERTAIN REFERRALS AND
  SOLICITATIONS. (a) A health benefit plan issuer or pharmacy
  benefit manager may not require a patient to use the issuer's or
  manager's affiliated provider in order for the patient to receive
  the maximum benefit for the service under the patient's health
  benefit plan.
         (b)  A health benefit plan issuer or pharmacy benefit manager
  may not offer or implement a health benefit plan that requires or
  induces a patient to use the issuer's or manager's affiliated
  provider, including by providing for reduced cost-sharing if the
  patient uses the affiliated provider.
         (c)  A health benefit plan issuer or pharmacy benefit manager
  may not solicit a patient or prescriber to transfer a patient
  prescription to the issuer's or manager's affiliated provider.
         (d)  A health benefit plan issuer or pharmacy benefit manager
  may not require a pharmacy or durable medical equipment provider
  that is not the issuer's or manager's affiliated provider to
  transfer a patient's prescription to the issuer's or manager's
  affiliated provider without the prior written consent of the
  patient.
         SECTION 2.  Subchapter B, Chapter 531, Government Code, is
  amended by adding Section 531.0695 to read as follows:
         Sec. 531.0695.  REQUIRED FEE SCHEDULE FOR CERTAIN PHARMACY
  BENEFITS PROVIDED UNDER MEDICAID OR CHILD HEALTH PLAN PROGRAM. (a)
  In this section, "pharmacy benefit manager" has the meaning
  assigned by Section 4151.151, Insurance Code.
         (b)  A contract between a pharmacy benefit manager and a
  managed care organization that contracts with the commission to
  provide pharmacy benefits under Medicaid or the child health plan
  program must contain a requirement that the pharmacy benefit
  manager have a fee schedule that applies to each pharmacy or
  pharmacist with which the pharmacy benefit manager contracts. The
  contract between the pharmacy benefit manager and the pharmacy or
  pharmacist must refer to the fee schedule and the pharmacy benefit
  manager shall provide the fee schedule:
               (1)  in the contract; or
               (2)  separately in an easy-to-access, electronic
  spreadsheet format and, on request by the pharmacy or pharmacist,
  in writing.
         (c)  A fee schedule provided under Subsection (b) must
  describe:
               (1)  specific pharmacy benefits that the pharmacy or
  pharmacist may deliver and the amount of the corresponding
  reimbursement for those benefits;
               (2)  the methodology used to calculate the
  reimbursement for specific pharmacy benefits; or
               (3)  another reasonable method that a pharmacy or
  pharmacist may use to ascertain the corresponding reimbursement
  amount for a specific pharmacy benefit.
         SECTION 3.  Sections 1369.554(a) and (b), Insurance Code, as
  added by this Act, apply only to a health benefit plan delivered,
  issued for delivery, or renewed on or after the effective date of
  this Act.
         SECTION 4.  Section 531.0695, Government Code, as added 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 5.  If before implementing any provision of this Act
  a state agency determines that a waiver or authorization from a
  federal agency is necessary for implementation of that provision,
  the agency affected by the provision shall request the waiver or
  authorization and may delay implementing that provision until the
  waiver or authorization is granted.
         SECTION 6.  This Act takes effect September 1, 2021.