BILL ANALYSIS

C.S.S.B. 493

By: Kolkhorst

Insurance

Committee Report (Substituted)

BACKGROUND AND PURPOSE

The bill sponsor has informed the committee that prescription copays differ by health plan but are typically less for generics than name-brand drugs; however, patients sometimes pay more in copays for generics than if they bought the same drugs at the cash price. Currently, the Texas Insurance Code protects physician and provider communication with patients, but it does not address communication with the enrollee about the cost of prescription drugs. C.S.S.B. 493 seeks to address this issue by prohibiting pharmacy benefit managers from restricting a pharmacist or pharmacy from informing an enrollee of any difference between the enrollee's out-of-pocket cost for a prescription drug under the enrollee's prescription drug benefit and the out-of-pocket cost without submitting a claim under the enrollee's prescription drug benefit.

CRIMINAL JUSTICE IMPACT

It is the committee's opinion that this bill does not expressly create a criminal offense, increase the punishment for an existing criminal offense or category of offenses, or change the eligibility of a person for community supervision, parole, or mandatory supervision.

RULEMAKING AUTHORITY

It is the committee's opinion that this bill does not expressly grant any additional rulemaking authority to a state officer, department, agency, or institution.

ANALYSIS

C.S.S.B. 493 amends the Insurance Code to prohibit a pharmacy benefit manager from, by contract or otherwise, prohibiting or restricting a pharmacist or pharmacy from informing an enrollee of any difference between the enrollee's out-of-pocket cost for a prescription drug under the enrollee's prescription drug benefit and the out-of-pocket cost without submitting a claim under the enrollee's prescription drug benefit.

C.S.S.B. 493 establishes that a provision in a pharmacy benefit manager's pharmacy benefit network contract is void and unenforceable if the provision prohibits or restricts a pharmacist or pharmacy from doing one of the following:

· informing an enrollee of any difference between the enrollee's out-of-pocket cost for a prescription drug under the enrollee's prescription drug benefit and the out-of-pocket cost without submitting a claim under the enrollee's prescription drug benefit; or

· communicating with plan sponsors or administrators regarding member services with respect to prescription drug benefits, pharmacy services and benefits, network access and adequacy with respect to prescription drug benefits, partnership opportunities, or prescription claim reimbursement.

C.S.S.B. 493 applies only to a contract or agreement entered into, amended, or renewed on or after the bill's effective date.

EFFECTIVE DATE

September 1, 2025.

COMPARISON OF SENATE ENGROSSED AND SUBSTITUTE

While C.S.S.B. 493 may differ from the engrossed in minor or nonsubstantive ways, the following summarizes the substantial differences between the engrossed and committee substitute versions of the bill.

The substitute omits a provision from the engrossed that defined "enrollee" for purposes of the bill's provisions.

The substitute includes a provision absent from the engrossed prohibiting a pharmacy benefit manager, by contract or otherwise, from prohibiting or restricting a pharmacist or pharmacy from informing an enrollee of any difference between the enrollee's out-of-pocket cost for a prescription drug under the enrollee's prescription drug benefit and the out-of-pocket cost without submitting a claim under the enrollee's prescription drug benefit.

Whereas the engrossed prohibited a pharmacist or pharmacy from entering into a contract or agreement or implementing or effectuating a policy that prohibits or restricts the pharmacist or pharmacy from informing an enrollee of any difference between the enrollee's out-of-pocket cost for a prescription drug under the enrollee's health benefit plan and the out-of-pocket cost without submitting a claim under the enrollee's health benefit plan or communicating with sponsors of an enrollee's health benefit plan regarding certain member services, the substitute establishes that a provision in a pharmacy benefit manager's pharmacy benefit network contract is void and unenforceable if the provision prohibits or restricts a pharmacist or pharmacy from informing an enrollee of any difference between the enrollee's out-of-pocket cost for a prescription drug under the enrollee's prescription drug benefit and the out-of-pocket cost without submitting a claim under the enrollee's prescription drug benefit or communicating with plan sponsors or administrators regarding those member services.

Whereas the engrossed made the bill's provisions applicable only to a contract or agreement entered into or amended on or after the bill's effective date, the substitute makes the bill's provisions applicable only to a contract or agreement entered into, amended, or renewed on or after the bill's effective date.