89R4791 JG-F

By: Oliverson H.B. No. 4533

A BILL TO BE ENTITLED

AN ACT

relating to the reimbursement of prescription drugs under Medicaid and the child health plan program.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Subchapter F, Chapter 540, Government Code, as effective April 1, 2025, is amended by adding Section 540.02731 to read as follows:

Sec. 540.02731. PHARMACY BENEFIT PLAN: REIMBURSEMENT METHODOLOGY FOR PRESCRIPTION DRUGS; STUDY. (a) Notwithstanding any other law and in accordance with rules the executive commissioner adopts, a Medicaid managed care organization or a pharmacy benefit manager administering a pharmacy benefit program on behalf of the organization shall reimburse a pharmacy or pharmacist, including a Texas retail pharmacy or a Texas specialty pharmacy, that dispenses a prescribed prescription drug to a recipient an amount that is not less than the lesser of:

(1) the reimbursement amount for the drug under the vendor drug program, including a dispensing fee that is not less than the dispensing fee for the drug under the vendor drug program; or

(2) the amount claimed by the pharmacy or pharmacist, including the gross amount due or the usual and customary charge to the public for the drug.

(b) The methodology the executive commissioner adopts by rule to determine Texas pharmacies' actual acquisition cost (AAC) for purposes of the vendor drug program must be consistent with the actual prices Texas retail pharmacies, Texas specialty pharmacies, and Texas long-term care pharmacies, as applicable, pay to acquire prescription drugs.

(c) The executive commissioner shall develop a process for determining Texas pharmacies' actual acquisition cost (AAC) for prescription drugs that:

(1) to the extent possible, bases the cost on cost data obtained from surveys of Texas pharmacies, including retail, specialty, and long-term care pharmacies, conducted by the commission on at least a monthly basis; and

(2) uses an alternative method for determining the cost with respect to prescription drugs for which insufficient cost data is available from surveys conducted under Subdivision (1).

(d) The executive commissioner may require Texas pharmacies to respond or submit information in response to surveys described by Subsection (c)(1) as a condition of participation as a Medicaid provider.

(e) The dispensing fees the executive commissioner adopts under Subsection (a) must be based on, as appropriate:

(1) Texas retail pharmacies' professional dispensing costs for retail prescription drugs; or

(2) Texas specialty pharmacies' professional dispensing costs for specialty prescription drugs.

(f) At least once every two years, the commission shall conduct a study of Texas pharmacies' dispensing costs for retail prescription drugs and specialty prescription drugs. Based on the results of the study, the executive commissioner shall adjust the minimum amount of the retail pharmacy professional dispensing fee and specialty pharmacy professional dispensing fee under Subsection (a).

(g) A contract to which this subchapter applies must require the contracting Medicaid managed care organization and any subcontracted pharmacy benefit manager to comply with Subsection (a).

SECTION 2. Subchapter D, Chapter 62, Health and Safety Code, is amended by adding Section 62.160 to read as follows:

Sec. 62.160. PHARMACY BENEFIT PLAN: REIMBURSEMENT METHODOLOGY FOR PRESCRIPTION DRUGS. A managed care organization providing pharmacy benefits under the child health plan program or a pharmacy benefit manager administering a pharmacy benefit program on behalf of the organization shall comply with Section 540.02731, Government Code.

SECTION 3. 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 4. This Act takes effect March 1, 2026.