Texas 2013 - 83rd Regular

Texas House Bill HB3262 Compare Versions

The same version is selected twice. Please select two different versions to compare.

Version 1 (Old)

Version 2 (New)

Old	New	Differences
1	1	83R24982 PMO-D
2	2	By: Miller of Comal H.B. No. 3262
3	3	Substitute the following for H.B. No. 3262:
4	4	By: Sheffield of Coryell C.S.H.B. No. 3262
5	5
6	6
7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to pharmacy benefit managers contracting with the child
10	10	health plan program, the Medicaid managed care program, and health
11	11	plans for certain government employees.
12	12	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
13	13	SECTION 1. Chapter 531, Government Code, is amended by
14	14	adding Subchapter Y to read as follows:
15	15	SUBCHAPTER Y. PHARMACY BENEFIT MANAGERS
16	16	Sec. 531.990. APPLICABILITY. This subchapter applies only
17	17	to a Medicaid managed care program under Chapter 533 and the child
18	18	health plan program.
19	19	Sec. 531.991. TRANSPARENCY IN PHARMACY BENEFIT MANAGEMENT.
20	20	(a) In this section, "maximum allowable cost" means a maximum
21	21	reimbursement amount for a group of therapeutically and
22	22	pharmaceutically equivalent multiple source medications.
23	23	(b) Each contract to provide pharmacy benefit manager
24	24	services must require the pharmacy benefit manager to:
25	25	(1) establish:
26	26	(A) a method of calculating, updating, and
27	27	revising a maximum allowable cost for each covered medication;
28	28	(B) intervals not to exceed seven days for
29	29	updating or revising the maximum allowable cost for each medication
30	30	on the maximum allowable cost list; and
31	31	(C) for that contract a single maximum allowable
32	32	cost list that uniformly serves as a basis for the calculation of
33	33	reimbursement amounts for pharmacy claims covered by the child
34	34	health plan program or Medicaid managed care program;
35	35	(2) develop and maintain a public Internet website and
36	36	post and maintain on the website the information required by
37	37	Subdivision (1)(C);
38	38	(3) notify each retail pharmacy affected by a
39	39	modification of a maximum allowable cost of the modification on the
40	40	date of the modification;
41	41	(4) disclose the data sources from which the pharmacy
42	42	benefit manager obtains pricing data used in establishing a maximum
43	43	allowable cost; and
44	44	(5) not less frequently than once a week, notify each
45	45	retail pharmacy affected by the pharmacy benefit manager's
46	46	substitution or deletion of, or addition to, a data source from
47	47	which the pharmacy benefit manager obtains pricing data used in
48	48	establishing a maximum allowable cost of the substitution,
49	49	deletion, or addition.
50	50	(c) A contract to provide pharmacy benefit manager services
51	51	must require the pharmacy benefit manager to provide to the
52	52	commission the information described by Subsections (b)(1)(B) and
53	53	(C). On request, the commission shall provide the information to a
54	54	pharmacist or pharmacy.
55	55	(d) A contract to provide pharmacy benefit manager services
56	56	must require that each medication on a maximum allowable cost list:
57	57	(1) is listed as "A" or "B" rated in the most recent
58	58	version of the United States Food and Drug Administration's Drug
59	59	Products with Therapeutic Equivalence Evaluations, also known as
60	60	the Orange Book;
61	61	(2) is rated "NR" or "NA" by Medi-Span; or
62	62	(3) has a similar rating by a nationally recognized
63	63	reference.
64	64	(e) A contract to provide pharmacy benefit manager services
65	65	must require the pharmacy benefit manager to:
66	66	(1) provide a procedure for a retail pharmacy to
67	67	challenge a listed maximum allowable cost;
68	68	(2) respond to a challenge under that procedure not
69	69	later than the 15th day after the date the challenge is made;
70	70	(3) if the challenge is successful, adjust the maximum
71	71	allowable cost effective on the date the challenge is resolved and
72	72	apply the adjustment to all retail pharmacies under the contract;
73	73	(4) if the challenge is denied, provide each reason
74	74	for the denial; and
75	75	(5) report every 90 days to the commission the total
76	76	number of challenges made and denied in the preceding 90-day period
77	77	to the maximum allowable cost for each medication the maximum
78	78	allowable cost of which was challenged during that period.
79	79	SECTION 2. Subchapter B, Chapter 1551, Insurance Code, is
80	80	amended by adding Section 1551.0671 to read as follows:
81	81	Sec. 1551.0671. TRANSPARENCY IN PHARMACY BENEFIT
82	82	MANAGEMENT. (a) In this section, "maximum allowable cost" means a
83	83	maximum reimbursement amount for a group of therapeutically and
84	84	pharmaceutically equivalent multiple source medications.
85	85	(b) Each contract to provide pharmacy benefit manager
86	86	services must require the pharmacy benefit manager to:
87	87	(1) establish:
88	88	(A) a method of calculating, updating, and
89	89	revising a maximum allowable cost for each covered medication;
90	90	(B) intervals not to exceed seven days for
91	91	updating or revising the maximum allowable cost for each medication
92	92	on the maximum allowable cost list; and
93	93	(C) for that contract a single maximum allowable
94	94	cost list that uniformly serves as a basis for the calculation of
95	95	reimbursement amounts for pharmacy claims covered by the group
96	96	benefits program;
97	97	(2) develop and maintain a public Internet website and
98	98	post and maintain on the website the information required by
99	99	Subdivision (1)(C);
100	100	(3) notify each retail pharmacy affected by a
101	101	modification of a maximum allowable cost of the modification on the
102	102	date of the modification;
103	103	(4) disclose the data sources from which the pharmacy
104	104	benefit manager obtains pricing data used in establishing a maximum
105	105	allowable cost; and
106	106	(5) not less frequently than once a week, notify each
107	107	retail pharmacy affected by the pharmacy benefit manager's
108	108	substitution or deletion of, or addition to, a data source from
109	109	which the pharmacy benefit manager obtains pricing data used in
110	110	establishing a maximum allowable cost of the substitution,
111	111	deletion, or addition.
112	112	(c) A contract to provide pharmacy benefit manager services
113	113	must require the pharmacy benefit manager to provide to the board of
114	114	trustees the information described by Subsections (b)(1)(B) and
115	115	(C). On request, the board of trustees shall provide the
116	116	information to a pharmacist or pharmacy.
117	117	(d) A contract to provide pharmacy benefit manager services
118	118	must require that each medication on a maximum allowable cost list:
119	119	(1) is listed as "A" or "B" rated in the most recent
120	120	version of the United States Food and Drug Administration's Drug
121	121	Products with Therapeutic Equivalence Evaluations, also known as
122	122	the Orange Book;
123	123	(2) is rated "NR" or "NA" by Medi-Span; or
124	124	(3) has a similar rating by a nationally recognized
125	125	reference.
126	126	(e) A contract to provide pharmacy benefit manager services
127	127	must require the pharmacy benefit manager to:
128	128	(1) provide a procedure for a retail pharmacy to
129	129	challenge a listed maximum allowable cost;
130	130	(2) respond to a challenge under that procedure not
131	131	later than the 15th day after the date the challenge is made;
132	132	(3) if the challenge is successful, adjust the maximum
133	133	allowable cost effective on the date the challenge is resolved and
134	134	apply the adjustment to all retail pharmacies under the contract;
135	135	(4) if the challenge is denied, provide each reason
136	136	for the denial; and
137	137	(5) report every 90 days to the board of trustees the
138	138	total number of challenges made and denied in the preceding 90-day
139	139	period to the maximum allowable cost for each medication the
140	140	maximum allowable cost of which was challenged during that period.
141	141	SECTION 3. Subchapter C, Chapter 1575, Insurance Code, is
142	142	amended by adding Section 1575.111 to read as follows:
143	143	Sec. 1575.111. TRANSPARENCY IN PHARMACY BENEFIT
144	144	MANAGEMENT. (a) In this section, "maximum allowable cost" means a
145	145	maximum reimbursement amount for a group of therapeutically and
146	146	pharmaceutically equivalent multiple source medications.
147	147	(b) Each contract to provide pharmacy benefit manager
148	148	services must require the pharmacy benefit manager to:
149	149	(1) establish:
150	150	(A) a method of calculating, updating, and
151	151	revising a maximum allowable cost for each covered medication;
152	152	(B) intervals not to exceed seven days for
153	153	updating or revising the maximum allowable cost for each medication
154	154	on the maximum allowable cost list; and
155	155	(C) for that contract a single maximum allowable
156	156	cost list that uniformly serves as a basis for the calculation of
157	157	reimbursement amounts for pharmacy claims covered by the group
158	158	program;
159	159	(2) develop and maintain a public Internet website and
160	160	post and maintain on the website the information required by
161	161	Subdivision (1)(C);
162	162	(3) notify each retail pharmacy affected by a
163	163	modification of a maximum allowable cost of the modification on the
164	164	date of the modification;
165	165	(4) disclose the data sources from which the pharmacy
166	166	benefit manager obtains pricing data used in establishing a maximum
167	167	allowable cost; and
168	168	(5) not less frequently than once a week, notify each
169	169	retail pharmacy affected by the pharmacy benefit manager's
170	170	substitution or deletion of, or addition to, a data source from
171	171	which the pharmacy benefit manager obtains pricing data used in
172	172	establishing a maximum allowable cost of the substitution,
173	173	deletion, or addition.
174	174	(c) A contract to provide pharmacy benefit manager services
175	175	must require the pharmacy benefit manager to provide to the trustee
176	176	the information described by Subsections (b)(1)(B) and (C). On
177	177	request, the trustee shall provide the information to a pharmacist
178	178	or pharmacy.
179	179	(d) A contract to provide pharmacy benefit manager services
180	180	must require that each medication on a maximum allowable cost list:
181	181	(1) is listed as "A" or "B" rated in the most recent
182	182	version of the United States Food and Drug Administration's Drug
183	183	Products with Therapeutic Equivalence Evaluations, also known as
184	184	the Orange Book;
185	185	(2) is rated "NR" or "NA" by Medi-Span; or
186	186	(3) has a similar rating by a nationally recognized
187	187	reference.
188	188	(e) A contract to provide pharmacy benefit manager services
189	189	must require the pharmacy benefit manager to:
190	190	(1) provide a procedure for a retail pharmacy to
191	191	challenge a listed maximum allowable cost;
192	192	(2) respond to a challenge under that procedure not
193	193	later than the 15th day after the date the challenge is made;
194	194	(3) if the challenge is successful, adjust the maximum
195	195	allowable cost effective on the date the challenge is resolved and
196	196	apply the adjustment to all retail pharmacies under the contract;
197	197	(4) if the challenge is denied, provide each reason
198	198	for the denial; and
199	199	(5) report every 90 days to the trustee the total
200	200	number of challenges made and denied in the preceding 90-day period
201	201	to the maximum allowable cost for each medication the maximum
202	202	allowable cost of which was challenged during that period.
203	203	SECTION 4. Subchapter B, Chapter 1579, Insurance Code, is
204	204	amended by adding Section 1579.058 to read as follows:
205	205	Sec. 1579.058. TRANSPARENCY IN PHARMACY BENEFIT
206	206	MANAGEMENT. (a) In this section, "maximum allowable cost" means a
207	207	maximum reimbursement amount for a group of therapeutically and
208	208	pharmaceutically equivalent multiple source medications.
209	209	(b) Each contract to provide pharmacy benefit manager
210	210	services must require the pharmacy benefit manager to:
211	211	(1) establish:
212	212	(A) a method of calculating, updating, and
213	213	revising a maximum allowable cost for each covered medication;
214	214	(B) intervals not to exceed seven days for
215	215	updating or revising the maximum allowable cost for each medication
216	216	on the maximum allowable cost list; and
217	217	(C) for that contract a single maximum allowable
218	218	cost list that uniformly serves as a basis for the calculation of
219	219	reimbursement amounts for pharmacy claims covered by a health
220	220	coverage plan;
221	221	(2) develop and maintain a public Internet website and
222	222	post and maintain on the website the information required by
223	223	Subdivision (1)(C);
224	224	(3) notify each retail pharmacy affected by a
225	225	modification of a maximum allowable cost of the modification on the
226	226	date of the modification;
227	227	(4) disclose the data sources from which the pharmacy
228	228	benefit manager obtains pricing data used in establishing a maximum
229	229	allowable cost; and
230	230	(5) not less frequently than once a week, notify each
231	231	retail pharmacy affected by the pharmacy benefit manager's
232	232	substitution or deletion of, or addition to, a data source from
233	233	which the pharmacy benefit manager obtains pricing data used in
234	234	establishing a maximum allowable cost of the substitution,
235	235	deletion, or addition.
236	236	(c) A contract to provide pharmacy benefit manager services
237	237	must require the pharmacy benefit manager to provide to the trustee
238	238	the information described by Subsections (b)(1)(B) and (C). On
239	239	request, the trustee shall provide the information to a pharmacist
240	240	or pharmacy.
241	241	(d) A contract to provide pharmacy benefit manager services
242	242	must require that each medication on a maximum allowable cost list:
243	243	(1) is listed as "A" or "B" rated in the most recent
244	244	version of the United States Food and Drug Administration's Drug
245	245	Products with Therapeutic Equivalence Evaluations, also known as
246	246	the Orange Book;
247	247	(2) is rated "NR" or "NA" by Medi-Span; or
248	248	(3) has a similar rating by a nationally recognized
249	249	reference.
250	250	(e) A contract to provide pharmacy benefit manager services
251	251	must require the pharmacy benefit manager to:
252	252	(1) provide a procedure for a retail pharmacy to
253	253	challenge a listed maximum allowable cost;
254	254	(2) respond to a challenge under that procedure not
255	255	later than the 15th day after the date the challenge is made;
256	256	(3) if the challenge is successful, adjust the maximum
257	257	allowable cost effective on the date the challenge is resolved and
258	258	apply the adjustment to all retail pharmacies under the contract;
259	259	(4) if the challenge is denied, provide each reason
260	260	for the denial; and
261	261	(5) report every 90 days to the trustee the total
262	262	number of challenges made and denied in the preceding 90-day period
263	263	to the maximum allowable cost for each medication the maximum
264	264	allowable cost of which was challenged during that period.
265	265	SECTION 5. Subchapter B, Chapter 1601, Insurance Code, is
266	266	amended by adding Section 1601.065 to read as follows:
267	267	Sec. 1601.065. TRANSPARENCY IN PHARMACY BENEFIT
268	268	MANAGEMENT. (a) In this section, "maximum allowable cost" means a
269	269	maximum reimbursement amount for a group of therapeutically and
270	270	pharmaceutically equivalent multiple source medications.
271	271	(b) Each contract to provide pharmacy benefit manager
272	272	services must require the pharmacy benefit manager to:
273	273	(1) establish:
274	274	(A) a method of calculating, updating, and
275	275	revising a maximum allowable cost for each covered medication;
276	276	(B) intervals not to exceed seven days for
277	277	updating or revising the maximum allowable cost for each medication
278	278	on the maximum allowable cost list; and
279	279	(C) for that contract a single maximum allowable
280	280	cost list that uniformly serves as a basis for the calculation of
281	281	reimbursement amounts for pharmacy claims covered by the basic
282	282	coverage;
283	283	(2) develop and maintain a public Internet website and
284	284	post and maintain on the website the information required by
285	285	Subdivision (1)(C);
286	286	(3) notify each retail pharmacy affected by a
287	287	modification of a maximum allowable cost of the modification on the
288	288	date of the modification;
289	289	(4) disclose the data sources from which the pharmacy
290	290	benefit manager obtains pricing data used in establishing a maximum
291	291	allowable cost; and
292	292	(5) not less frequently than once a week, notify each
293	293	retail pharmacy affected by the pharmacy benefit manager's
294	294	substitution or deletion of, or addition to, a data source from
295	295	which the pharmacy benefit manager obtains pricing data used in
296	296	establishing a maximum allowable cost of the substitution,
297	297	deletion, or addition.
298	298	(c) A contract to provide pharmacy benefit manager services
299	299	must require the pharmacy benefit manager to provide to the
300	300	governing board of the system the information described by
301	301	Subsections (b)(1)(B) and (C). On request, the system shall
302	302	provide the information to a pharmacist or pharmacy.
303	303	(d) A contract to provide pharmacy benefit manager services
304	304	must require that each medication on a maximum allowable cost list:
305	305	(1) is listed as "A" or "B" rated in the most recent
306	306	version of the United States Food and Drug Administration's Drug
307	307	Products with Therapeutic Equivalence Evaluations, also known as
308	308	the Orange Book;
309	309	(2) is rated "NR" or "NA" by Medi-Span; or
310	310	(3) has a similar rating by a nationally recognized
311	311	reference.
312	312	(e) A contract to provide pharmacy benefit manager services
313	313	must require the pharmacy benefit manager to:
314	314	(1) provide a procedure for a retail pharmacy to
315	315	challenge a listed maximum allowable cost;
316	316	(2) respond to a challenge under that procedure not
317	317	later than the 15th day after the date the challenge is made;
318	318	(3) if the challenge is successful, adjust the maximum
319	319	allowable cost effective on the date the challenge is resolved and
320	320	apply the adjustment to all retail pharmacies under the contract;
321	321	(4) if the challenge is denied, provide each reason
322	322	for the denial; and
323	323	(5) report every 90 days to the system the total number
324	324	of challenges made and denied in the preceding 90-day period to the
325	325	maximum allowable cost for each medication the maximum allowable
326	326	cost of which was challenged during that period.
327	327	SECTION 6. Subchapter Y, Chapter 531, Government Code, and
328	328	Sections 1551.0671, 1575.111, 1579.058, and 1601.065, Insurance
329	329	Code, as added by this Act, apply only to a contract with a pharmacy
330	330	benefit manager entered into or renewed on or after the effective
331	331	date of this Act.
332	332	SECTION 7. This Act takes effect September 1, 2013.