87R19295 JES/KFF-F
 
  By: Kolkhorst S.B. No. 2195
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to the relationship between pharmacists or pharmacies and
  pharmacy benefit managers or health benefit plan issuers, including
  relationships governed by contracts with managed care
  organizations under Medicaid and the child health plan program.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  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 2.  Subchapter D, Chapter 4151, Insurance Code, is
  amended by adding Section 4151.155 to read as follows:
         Sec. 4151.155.  REDUCTION OF CERTAIN CLAIM PAYMENT AMOUNTS
  PROHIBITED. (a) A 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, a quality assurance program, other
  direct or indirect remuneration fee, or otherwise, except in
  accordance with an audit.
         (b)  Nothing in this section prohibits a pharmacy benefit
  manager from increasing a claim payment amount after adjudication
  of the claim.
         (c)  Notwithstanding any other law, this section applies to
  the Medicaid managed care program operated under Chapter 533,
  Government Code.
         SECTION 3.  Chapter 562, Occupations Code, is amended by
  adding Subchapter E to read as follows:
  SUBCHAPTER E. CONTRACTS WITH PHARMACISTS AND PHARMACIES
         Sec. 562.201.  DEFINITION. In this subchapter, "pharmacy
  benefit manager" has the meaning assigned by Section 4151.151,
  Insurance Code.
         Sec. 562.202.  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, Insurance Code;
               (3)  a health maintenance organization operating under
  Chapter 843, Insurance Code;
               (4)  an approved nonprofit health corporation that
  holds a certificate of authority under Chapter 844, Insurance Code;
               (5)  a multiple employer welfare arrangement that holds
  a certificate of authority under Chapter 846, Insurance Code;
               (6)  a stipulated premium company operating under
  Chapter 884, Insurance Code;
               (7)  a fraternal benefit society operating under
  Chapter 885, Insurance Code;
               (8)  a Lloyd's plan operating under Chapter 941,
  Insurance Code; or
               (9)  an exchange operating under Chapter 942, Insurance
  Code.
         (b)  Notwithstanding any other law, this subchapter applies
  to:
               (1)  a small employer health benefit plan subject to
  Chapter 1501, Insurance Code, including coverage provided through a
  health group cooperative under Subchapter B of that chapter;
               (2)  a standard health benefit plan issued under
  Chapter 1507, Insurance Code;
               (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.
         Sec. 562.203.  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, including a specialty drug, that may be
  dispensed under the pharmacist's or pharmacy's license unless
  applicable state or federal law prohibits the pharmacist or
  pharmacy from dispensing the drug.
         Sec. 562.204.  RESTRICTIONS ON MAIL ORDER PHARMACY SERVICES.
  A pharmacy benefit manager may not require an enrollee to use a mail
  order pharmacy.
         Sec. 562.205.  DELIVERY OF DRUGS. 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.
         Sec. 562.206.  WAIVER PROHIBITED. The provisions of this
  subchapter may not be waived, voided, or nullified by contract.
         SECTION 4.  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 5.  This Act takes effect September 1, 2021.