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A BILL TO BE ENTITLED
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AN ACT
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relating to the minimum reimbursement amount for prescription drugs |
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and devices to health benefit plan network pharmacists and |
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pharmacies. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Chapter 1369, Insurance Code, is amended by |
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adding Subchapter H-1 to read as follows: |
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SUBCHAPTER H-1. MINIMUM REIMBURSEMENT AMOUNT FOR NETWORK |
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PHARMACISTS AND PHARMACIES |
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Sec. 1369.371. DEFINITIONS. In this subchapter: |
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(1) "Health benefit plan" has the meaning assigned by |
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Section 1369.251. |
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(2) "Pharmacy benefit manager" means: |
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(A) a pharmacy benefit manager, as defined by |
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Section 4151.151; or |
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(B) a health benefit plan issuer or sponsor that |
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administers pharmacy benefits in connection with the health benefit |
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plan. |
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Sec. 1369.372. APPLICABILITY OF SUBCHAPTER. This |
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subchapter applies to the administration of pharmacy benefits by or |
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on behalf of an issuer or sponsor of a health benefit plan. |
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Sec. 1369.373. EXCEPTIONS TO APPLICABILITY OF |
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SUBCHAPTER. This subchapter does not apply to an issuer or |
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provider of health benefits under or a pharmacy benefit manager |
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administering pharmacy benefits under: |
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(1) the state Medicaid program, including the Medicaid |
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managed care program operated under Chapter 540, Government Code; |
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(2) the child health plan program under Chapter 62, |
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Health and Safety Code; |
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(3) the TRICARE military health system; |
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(4) a basic coverage plan under Chapter 1551; |
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(5) a basic plan under Chapter 1575; |
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(6) a coverage plan under Chapter 1579; |
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(7) a plan providing basic coverage under Chapter |
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1601; or |
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(8) a workers' compensation insurance policy or other |
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form of providing medical benefits under Title 5, Labor Code. |
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Sec. 1369.374. REIMBURSEMENT MINIMUM; DISPENSING FEES. |
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(a) Notwithstanding any other law and subject to Subsection (c), a |
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pharmacy benefit manager may not reimburse a pharmacist or pharmacy |
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under contract with the pharmacy benefit manager for a prescription |
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drug or device an amount that is less than the actual cost to that |
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pharmacist or pharmacy for the drug or device. |
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(b) Subsection (a) does not apply to a pharmacy benefit |
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manager using an ingredient cost reimbursement methodology for a |
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prescription drug or device that is identical to the reimbursement |
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methodology for the ingredient cost of the drug or device under the |
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Medicaid fee-for-service model. |
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(c) In calculating the reimbursement amount for a |
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prescription drug or device under Subsection (a), a pharmacy |
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benefit manager may not include in that calculation the amount of a |
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professional dispensing fee payable to the pharmacist or pharmacy |
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that dispensed the drug or device. |
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(d) A pharmacy benefit manager shall reimburse a pharmacist |
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or pharmacy under contract with the pharmacy benefit manager a |
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professional dispensing fee for a prescription drug or device in an |
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amount that is not less than the amount of the dispensing fee paid |
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for the drug or device under the Medicaid fee-for-service model. |
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Sec. 1369.375. APPEAL: PROCEDURES REQUIRED. (a) A |
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pharmacy benefit manager shall provide in the contract with each |
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pharmacist or pharmacy a procedure for the pharmacist or pharmacy |
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to appeal a reimbursement of a prescription drug or device that the |
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pharmacist or pharmacy alleges to not be in compliance with Section |
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1369.374 on or before the seventh day after the date the |
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reimbursement is provided. |
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(b) The appeal procedure provision must: |
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(1) be approved by the commissioner; and |
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(2) permit a pharmacist or pharmacy or the |
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pharmacist's or pharmacy's designated agent to file an appeal using |
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the standard appeal form described by Subsection (d). |
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(c) A pharmacy benefit manager shall file an appeal |
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procedure provision with the department in the form and manner |
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prescribed by the commissioner. |
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(d) The commissioner shall develop and make available to |
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pharmacy benefit managers a standard appeal form to be used to file |
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an appeal of a reimbursement alleged to not be in compliance with |
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Section 1369.374. |
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Sec. 1369.376. APPEAL: PHARMACIST OR PHARMACY AGENT. A |
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pharmacist or pharmacy electing to appeal a reimbursement under a |
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procedure described by Section 1369.375 may designate a pharmacy |
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services administrative organization or another agent to file and |
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conduct the appeal. |
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Sec. 1369.377. APPEAL: EFFECT OF PHARMACIST OR PHARMACY |
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PREVAILING. (a) In this section, "similarly situated pharmacist |
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or pharmacy" means a pharmacist or pharmacy: |
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(1) that is under contract with the pharmacy benefit |
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manager; |
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(2) that purchases the prescription drug or device |
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that is the subject of an appeal of a reimbursement not in |
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compliance with Section 1369.374 from the same pharmaceutical |
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wholesaler as the pharmacist or pharmacy that prevailed in the |
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appeal; and |
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(3) to which the pharmacy benefit manager also applies |
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the challenged reimbursement rate or actual cost for the |
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prescription drug or device. |
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(b) If a pharmacist or pharmacy prevails in an appeal of a |
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reimbursement alleged to not be in compliance with Section |
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1369.374, the pharmacy benefit manager shall, not later than the |
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seventh day after the date the pharmacist or pharmacy prevailed: |
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(1) make the necessary change to the challenged |
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reimbursement or actual cost; |
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(2) if the product involved in the appeal is a |
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prescription drug, provide the pharmacist or pharmacy the national |
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drug code number for the drug; |
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(3) permit the pharmacist or pharmacy to reverse and |
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rebill the claim that is the subject of the appeal; |
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(4) pay or waive any transaction fee required to |
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reverse or rebill the claim; |
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(5) reimburse the pharmacist or pharmacy at least the |
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pharmacist's or pharmacy's actual cost for the prescription drug or |
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device; and |
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(6) apply the findings from the appeal to the |
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reimbursement rate and actual cost for the prescription drug or |
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device that is the subject of the appeal to other similarly situated |
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pharmacists and pharmacies. |
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Sec. 1369.378. APPEAL: EFFECT OF PHARMACY BENEFIT MANAGER |
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PREVAILING. (a) If a pharmacy benefit manager prevails in an |
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appeal of a reimbursement alleged to not be in compliance with |
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Section 1369.374 and the prescription drug or device that is the |
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subject of the appeal is available at a cost equal to or less than |
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the challenged reimbursement, the pharmacy benefit manager shall, |
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not later than the seventh day after the date the pharmacy benefit |
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manager prevails: |
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(1) provide the pharmacist or pharmacy with the name |
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of the national or regional pharmaceutical wholesaler operating in |
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this state that has the drug or device in stock at a price that is |
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equal to or less than the challenged reimbursement; and |
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(2) as applicable, provide the national drug code |
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number for the drug or the unique device identifier for the device. |
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(b) If a pharmacy benefit manager fails to comply with |
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Subsection (a), the pharmacy benefit manager shall: |
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(1) adjust the challenged reimbursement to an amount |
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equal to or greater than the pharmacist's or pharmacy's actual cost; |
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(2) permit the pharmacist or pharmacy to reverse and |
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rebill each claim affected by the inability to obtain the drug or |
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device at a cost equal to or less than the challenged reimbursement; |
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and |
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(3) pay or waive any transaction fee required to |
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reverse and rebill each affected claim. |
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SECTION 2. Subchapter H-1, Chapter 1369, Insurance Code, as |
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added by this Act, applies only to a health benefit plan delivered, |
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issued for delivery, or renewed on or after January 1, 2026. |
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SECTION 3. This Act takes effect September 1, 2025. |