81R7767 KCR-F
By: Gattis, Gonzalez Toureilles, et al. H.B. No. 2293
A BILL TO BE ENTITLED
AN ACT
relating to the delivery of prescription drugs for certain state
health plans by mail order; providing an administrative penalty.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle H, Title 8, Insurance Code, is amended
by adding Chapter 1560 to read as follows:
CHAPTER 1560. DELIVERY OF PRESCRIPTION DRUGS BY MAIL
Sec. 1560.001. DEFINITIONS. In this chapter:
(1) "Community retail pharmacy" means a pharmacy that
is licensed as a Class A pharmacy under Chapter 560, Occupations
Code.
(2) "Mail order pharmacy" means a pharmacy that is
licensed under Chapter 560, Occupations Code, and that primarily
delivers prescription drugs to an enrollee through the United
States Postal Service or a commercial delivery service.
(3) "Prescription drug formulary" means a list of
prescription drugs preferred for use and eligible for coverage
under a health benefit plan.
Sec. 1560.002. APPLICABILITY OF CHAPTER. This chapter
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 or
administered by:
(1) the Teacher Retirement System of Texas under
Chapter 1575 or 1579; or
(2) the Employees Retirement System of Texas under
Chapter 1551.
Sec. 1560.003. MULTIPLE-MONTH SUPPLY OF PRESCRIPTION DRUG.
(a) In this section, "multiple-month supply" means a supply for 60
or more days.
(b) Notwithstanding any other law, an issuer of a health
benefit plan that provides pharmacy benefits to enrollees must
allow an enrollee to obtain from a community retail pharmacy a
multiple-month supply of any prescription drug under the same terms
and conditions applicable when the prescription drug is obtained
from a mail order pharmacy, if the community retail pharmacy agrees
to accept reimbursement on exactly the same terms and conditions
that apply to a mail order pharmacy.
(c) This section does not require:
(1) the issuer of a health benefit plan to contract
with:
(A) a retail pharmacy that does not agree to
accept reimbursement on exactly the same terms and conditions that
apply to a mail order pharmacy; or
(B) more than one mail order pharmacy; or
(2) a community retail pharmacy to:
(A) provide a multiple-month supply of a
prescription drug under the same terms and conditions applicable
when the prescription drug is obtained from a mail order pharmacy;
or
(B) agree to accept reimbursement on exactly the
same terms and conditions that apply to a mail order pharmacy.
Sec. 1560.004. PRESCRIPTION DRUG REIMBURSEMENT RATES. (a)
An issuer of a health benefit plan that provides pharmacy benefits
to enrollees shall reimburse pharmacies participating in the health
plan using prescription drug reimbursement rates, for both brand
name and generic prescription drugs, that are based on a current and
nationally recognized benchmark index that includes average
wholesale price and maximum allowable cost.
(b) Regardless of whether a pharmacy is a mail order
pharmacy or a community retail pharmacy, an issuer of a health
benefit plan shall use the same benchmark index, including the same
average wholesale price, maximum allowable cost, and national
prescription drug codes, to reimburse all pharmacies participating
in the health benefit plan.
Sec. 1560.005. ACQUISITION COSTS AND REBATES. An issuer of
a health benefit plan that contracts with a third-party
administrator, pharmacy benefit manager, or other entity to manage
pharmacy benefits provided to enrollees through a mail order
pharmacy shall require the managing entity to:
(1) provide the issuer of the health benefit plan with
an annual electronic report containing:
(A) the actual acquisition cost of all drugs
purchased by the managing entity in relation to the pharmacy
benefits under the health benefit plan; and
(B) an identification of the source, type, and
amount of all rebates, rebate administrative fees, and other
monetary benefits received by the managing entity from a drug
manufacturer in relation to the pharmacy benefits under the health
benefit plan; and
(2) not later than the 30th day after the date the
managing entity receives a rebate, rebate administrative fee, or
other monetary benefit from a drug manufacturer in relation to the
pharmacy benefits under the health benefit plan, reimburse or
credit to the issuer of the health benefit plan an amount equal to
the amount of the rebate, rebate administrative fee, or other
monetary benefit received by the managing entity.
Sec. 1560.006. PHARMACY BENEFIT MANAGERS: DESIGNATION OF
CONFIDENTIAL INFORMATION. (a) A pharmacy benefit manager may
designate as confidential any information the pharmacy benefit
manager is required to disclose under Section 1560.005.
(b) Information designated as confidential under this
section may not be disclosed to any person without the consent of
the pharmacy benefit manager unless the disclosure is:
(1) ordered by a court for good cause shown;
(2) made under seal in a court filing; or
(3) made to the commissioner of insurance or the
attorney general in connection with an investigation authorized by
this code, the Government Code, or any other law.
Sec. 1560.007. COMPLAINT AND ENFORCEMENT; ADMINISTRATIVE
PENALTIES. (a) The department shall investigate any complaint
that the department receives concerning conduct regulated by this
chapter.
(b) Following an investigation under Subsection (a), the
commissioner shall issue a written determination of the outcome of
the investigation, including whether the department has taken or
intends to take any action under Chapters 81-86.
(c) If, as a result of a complaint investigated under
Subsection (a), the commissioner determines that an issuer of a
health benefit plan has violated this chapter, the commissioner
shall impose an administrative penalty against the issuer of the
health benefit plan in accordance with Chapter 84. The amount of an
administrative penalty imposed under this subsection may not exceed
$1,000 per prescription that was filled or that was not filled in
violation of this chapter. The limitation on the amount of an
administrative penalty under Section 84.022 does not apply to an
administrative penalty imposed under this subsection.
SECTION 2. Section 1551.224, Insurance Code, is amended to
read as follows:
Sec. 1551.224. MAIL ORDER REQUIREMENT FOR PRESCRIPTION DRUG
COVERAGE PROHIBITED. (a) The board of trustees or a health benefit
plan under this chapter that provides benefits for prescription
drugs may not require a participant in the group benefits program to
purchase a prescription drug through a mail order program.
(b) Except as provided by Subsection (c), the [The] board of
trustees or a health benefit plan shall require that a participant
who chooses to obtain a prescription drug through a retail pharmacy
or other method other than by mail order pay a deductible,
copayment, coinsurance, or other cost-sharing obligation to cover
the additional cost of obtaining a prescription drug through that
method rather than by mail order.
(c) The board of trustees or a health benefit plan may not
require a participant who obtains a multiple-month supply of a
prescription drug from a retail pharmacy under Section 1560.003 to
pay a deductible, copayment, coinsurance, or other cost-sharing
obligation that differs from the amount the participant pays for a
multiple-month supply of that drug through a mail order program.
SECTION 3. The change in law made by this Act applies only
to a health benefit plan that is delivered, issued for delivery, or
renewed on or after January 1, 2010. A health benefit plan that is
delivered, issued for delivery, or renewed before January 1, 2010,
is covered by the law in effect at the time the policy was
delivered, issued for delivery, or renewed, and that law is
continued in effect for that purpose.
SECTION 4. This Act takes effect September 1, 2009.