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A BILL TO BE ENTITLED
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AN ACT
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relating to the relationship between pharmacists or pharmacies and |
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health benefit plan issuers or pharmacy benefit managers. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 1369.153, Insurance Code, is amended by |
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adding Subsection (e) to read as follows: |
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(e) A group number on an identification card provided to an |
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enrollee in a health benefit plan to which this subchapter applies |
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may be assigned only to enrollees in a health benefit plan to which |
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this subchapter applies. |
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SECTION 2. The heading to Section 1369.259, Insurance Code, |
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is amended to read as follows: |
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Sec. 1369.259. LIMITATIONS ON PAYMENT ADJUSTMENTS AND |
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[CALCULATION OF] RECOUPMENT; USE OF EXTRAPOLATION PROHIBITED. |
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SECTION 3. Section 1369.259, Insurance Code, is amended by |
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adding Subsections (a-1), (e), and (f) to read as follows: |
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(a-1) Subject to Subsections (e) and (f), a health benefit |
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plan issuer or pharmacy benefit manager may not, as the result of an |
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audit, deny or reduce a claim payment made to a pharmacist or |
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pharmacy after adjudication of the claim. |
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(e) A health benefit plan issuer or pharmacy benefit manager |
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may recoup from a pharmacist or pharmacy the cost of a prescription |
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drug and the dispensing fee for the drug if: |
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(1) the original claim was submitted fraudulently; |
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(2) the original claim payment was incorrect because |
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the pharmacist or pharmacy had already been paid for the pharmacist |
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service; or |
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(3) the pharmacist or pharmacy made a substantive |
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nonclerical or non-recordkeeping error that led to the patient |
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receiving the wrong prescription drug or dosage. |
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(f) A health benefit plan issuer or pharmacy benefit manager |
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may recoup only the dispensing fee from a pharmacist or pharmacy if |
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the pharmacist or pharmacy made a clerical error that led to an |
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overpayment. |
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SECTION 4. Subchapter M, Chapter 1369, Insurance Code, is |
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amended by adding Sections 1369.6021, 1369.6022, 1369.6023, |
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1369.6024, 1369.6025, 1369.6026, and 1369.6027 to read as follows: |
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Sec. 1369.6021. ONLINE ACCESS TO PHARMACY BENEFIT NETWORK |
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CONTRACT. A health benefit plan issuer or pharmacy benefit manager |
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shall make available to any pharmacist or pharmacy in the issuer's |
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or manager's pharmacy benefit network access to a secure, online |
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portal through which the pharmacist or pharmacy may access all |
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pharmacy benefit network contracts between the health benefit plan |
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issuer or pharmacy benefit manager and the pharmacist or pharmacy, |
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including any contract addendums. |
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Sec. 1369.6022. PHARMACY BENEFIT NETWORK CONTRACT: ADVERSE |
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MATERIAL CHANGES. (a) In this section, "adverse material change" |
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means a modification or addendum to a pharmacy benefit network |
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contract that would decrease a pharmacist's or pharmacy's payment |
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or compensation, change the pharmacist's or pharmacy's tier to a |
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less preferred tier, or change the administrative procedures in a |
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way that may reasonably be expected to increase the pharmacist's or |
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pharmacy's administrative expenses or decrease the pharmacist's or |
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pharmacy's payment or compensation. The term does not include: |
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(1) a decrease in payment or compensation resulting |
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solely from a change in a published governmental fee schedule on |
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which the payment or compensation is based if the applicability of |
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the schedule is clearly identified in the contract; |
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(2) a decrease in payment or compensation that was |
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anticipated under the terms of the contract, if the amount and date |
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of applicability of the decrease is clearly identified in the |
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contract; |
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(3) an administrative change that may increase the |
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pharmacist's or pharmacy's administrative expenses, the specific |
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applicability of which is clearly identified in the contract; |
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(4) a change that is required by federal or state law; |
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(5) a termination for cause; or |
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(6) a termination without cause at the end of the term |
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of the contract. |
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(b) A health benefit plan issuer or pharmacy benefit manager |
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may make an adverse material change to a pharmacy benefit network |
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contract during the term of the contract only with the mutual |
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agreement of the parties. A provision in the contract that allows a |
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health benefit plan issuer or pharmacy benefit manager to |
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unilaterally make an adverse material change during the term of the |
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contract is void and unenforceable. |
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(c) An adverse material change to a pharmacy benefit network |
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contract may not go into effect until the 120th day after the date |
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the pharmacist or pharmacy affirmatively agrees to the adverse |
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material change in writing. |
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(d) An adverse material change to a pharmacy benefit network |
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contract proposed by a health benefit plan issuer or pharmacy |
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benefit manager must include notice that clearly and conspicuously |
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states that a pharmacist or pharmacy may choose to not agree to the |
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adverse material change and that the decision to not agree to the |
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adverse material change does not affect: |
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(1) the terms of the pharmacist's or pharmacy's |
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existing contract with the health benefit plan issuer or pharmacy |
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benefit manager; or |
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(2) the pharmacist's or pharmacy's participation in |
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another pharmacy benefit network. |
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(e) A pharmacist's or pharmacy's decision to not agree to an |
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adverse material change to a pharmacy benefit network contract does |
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not affect: |
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(1) the terms of the pharmacist's or pharmacy's |
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existing contract; or |
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(2) the pharmacist's or pharmacy's participation in |
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another pharmacy benefit network. |
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(f) A health benefit plan issuer's or pharmacy benefit |
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manager's failure to include the notice described by Subsection (d) |
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with the proposed adverse material change makes an otherwise |
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agreed-to adverse material change void and unenforceable. |
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(g) This section does not apply to: |
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(1) a pharmacy benefit network contract: |
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(A) with an unspecified and indefinite duration; |
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(B) with no stated or automatic renewal period or |
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event; and |
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(C) that may only be terminated by notice from |
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one party to the other; or |
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(2) a proposed modification or addendum to a pharmacy |
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benefit network contract that is required by state or federal law or |
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rule. |
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Sec. 1369.6023. PHARMACY BENEFIT NETWORK CONTRACT: OTHER |
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MODIFICATIONS AND ADDENDUMS. (a) A health benefit plan issuer or |
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pharmacy benefit manager must, not later than the 90th day before |
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the date a proposed modification or addendum to a pharmacy benefit |
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network contract, other than an adverse material change as defined |
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by Section 1369.6022, is to take effect: |
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(1) post the proposed modification or addendum to the |
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online portal described by Section 1369.6021; and |
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(2) provide to the pharmacist or pharmacy notice of |
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the proposed modification or addendum by e-mail, including: |
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(A) a link to the online portal; |
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(B) the National Council for Prescription Drug |
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Programs number or other identifier approved by the commissioner |
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for the pharmacist or pharmacy to which the proposed modification |
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or addendum applies; and |
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(C) a description of the proposed modification or |
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addendum in a manner that allows the pharmacist or pharmacy to |
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compare the proposed modification or addendum to the current |
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contract. |
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(b) If a pharmacist or pharmacy does not respond before the |
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31st day after the date the pharmacist or pharmacy receives notice |
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of a proposed modification or addendum under Subsection (a), the |
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health benefit plan issuer or pharmacy benefit manager may consider |
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the proposed modification or addendum approved by the pharmacist or |
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pharmacy and the modification or addendum takes effect on the date |
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described by Subsection (a). |
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(c) A pharmacy benefit network contract may not incorporate |
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by reference a document not included in a contract or contract |
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attachment, including a provider manual described by Section |
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1369.6025. All financial terms, including reimbursement rates and |
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methodology, must be set forth in the contract. |
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(d) This section does not apply to: |
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(1) a pharmacy benefit network contract: |
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(A) with an unspecified and indefinite duration; |
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(B) with no stated or automatic renewal period or |
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event; and |
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(C) that may only be terminated by notice from |
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one party to the other; or |
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(2) a proposed modification or addendum to a pharmacy |
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benefit network contract that is required by state or federal law or |
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rule. |
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Sec. 1369.6024. PHARMACY BENEFIT NETWORK CONTRACT |
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DISCLOSURE. A pharmacy benefit network contract must state that |
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the contract is subject to this chapter and any rules adopted by the |
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commissioner under this chapter. |
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Sec. 1369.6025. PROVIDER MANUAL DISCLOSURE. A health |
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benefit plan issuer or pharmacy benefit manager shall: |
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(1) make a provider manual readily available on the |
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online portal described by Section 1369.6021; and |
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(2) post a modification or addendum to the provider |
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manual to the online portal in the same manner as a contract |
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modification or addendum under Section 1369.6023(a). |
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Sec. 1369.6026. PHARMACY BENEFIT NETWORK CONTRACT FEE |
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LIMITATIONS. A health benefit plan issuer or pharmacy benefit |
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manager may not charge a fee, including an application or |
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participation fee, before providing a pharmacist or pharmacy with |
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the full proposed pharmacy benefit network contract, including any |
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financial terms applicable to the contract and corresponding |
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pharmacy benefit network. |
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Sec. 1369.6027. PHARMACY BENEFIT NETWORK PARTICIPATION |
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REQUIREMENTS PROHIBITED. A health benefit plan issuer or pharmacy |
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benefit manager may not: |
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(1) require a pharmacist or pharmacy to participate in |
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a pharmacy benefit network; |
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(2) condition a pharmacist's or pharmacy's |
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participation in a pharmacy benefit network on participation in any |
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other pharmacy benefit network; or |
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(3) penalize a pharmacist or pharmacy for refusing to |
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participate in a pharmacy benefit network. |
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SECTION 5. Section 1369.605, Insurance Code, is amended to |
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read as follows: |
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Sec. 1369.605. NETWORK CONTRACT FEE SCHEDULE. A pharmacy |
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benefit network contract must include [specify or reference] a |
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[separate] fee schedule. [Unless otherwise available in the |
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contract, the fee schedule must be provided electronically in an |
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easily accessible and complete spreadsheet format and, on request, |
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in writing to each contracted pharmacist and pharmacy.] The fee |
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schedule must describe: |
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(1) specific services or procedures that the |
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pharmacist or pharmacy may deliver and the amount of the |
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corresponding payment; |
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(2) a methodology for calculating the amount of the |
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payment based on a published fee schedule; or |
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(3) any other reasonable manner that provides an |
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ascertainable amount for payment for services. |
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SECTION 6. Section 1369.259(d), Insurance Code, is |
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repealed. |
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SECTION 7. (a) Section 1369.153, Insurance Code, as |
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amended by this Act, applies only to a health benefit plan |
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delivered, issued for delivery, or renewed on or after January 1, |
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2026. A health benefit plan delivered, issued for delivery, or |
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renewed before January 1, 2026, is governed by the law as it existed |
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immediately before the effective date of this Act, and that law is |
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continued in effect for that purpose. |
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(b) Chapter 1369, Insurance Code, as amended by this Act, |
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applies only to a contract entered into or renewed on or after the |
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effective date of this Act. A contract entered into or renewed |
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before the effective date of this Act is governed by the law as it |
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existed immediately before the effective date of this Act, and that |
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law is continued in effect for that purpose. |
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SECTION 8. This Act takes effect September 1, 2025. |
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* * * * * |