83R24982 PMO-D
By: Miller of Comal H.B. No. 3262
Substitute the following for H.B. No. 3262:
By: Sheffield of Coryell C.S.H.B. No. 3262
A BILL TO BE ENTITLED
AN ACT
relating to pharmacy benefit managers contracting with the child
health plan program, the Medicaid managed care program, and health
plans for certain government employees.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 531, Government Code, is amended by
adding Subchapter Y to read as follows:
SUBCHAPTER Y. PHARMACY BENEFIT MANAGERS
Sec. 531.990. APPLICABILITY. This subchapter applies only
to a Medicaid managed care program under Chapter 533 and the child
health plan program.
Sec. 531.991. TRANSPARENCY IN PHARMACY BENEFIT MANAGEMENT.
(a) In this section, "maximum allowable cost" means a maximum
reimbursement amount for a group of therapeutically and
pharmaceutically equivalent multiple source medications.
(b) Each contract to provide pharmacy benefit manager
services must require the pharmacy benefit manager to:
(1) establish:
(A) a method of calculating, updating, and
revising a maximum allowable cost for each covered medication;
(B) intervals not to exceed seven days for
updating or revising the maximum allowable cost for each medication
on the maximum allowable cost list; and
(C) for that contract a single maximum allowable
cost list that uniformly serves as a basis for the calculation of
reimbursement amounts for pharmacy claims covered by the child
health plan program or Medicaid managed care program;
(2) develop and maintain a public Internet website and
post and maintain on the website the information required by
Subdivision (1)(C);
(3) notify each retail pharmacy affected by a
modification of a maximum allowable cost of the modification on the
date of the modification;
(4) disclose the data sources from which the pharmacy
benefit manager obtains pricing data used in establishing a maximum
allowable cost; and
(5) not less frequently than once a week, notify each
retail pharmacy affected by the pharmacy benefit manager's
substitution or deletion of, or addition to, a data source from
which the pharmacy benefit manager obtains pricing data used in
establishing a maximum allowable cost of the substitution,
deletion, or addition.
(c) A contract to provide pharmacy benefit manager services
must require the pharmacy benefit manager to provide to the
commission the information described by Subsections (b)(1)(B) and
(C). On request, the commission shall provide the information to a
pharmacist or pharmacy.
(d) A contract to provide pharmacy benefit manager services
must require that each medication on a maximum allowable cost list:
(1) is listed as "A" or "B" rated in the most recent
version of the United States Food and Drug Administration's Drug
Products with Therapeutic Equivalence Evaluations, also known as
the Orange Book;
(2) is rated "NR" or "NA" by Medi-Span; or
(3) has a similar rating by a nationally recognized
reference.
(e) A contract to provide pharmacy benefit manager services
must require the pharmacy benefit manager to:
(1) provide a procedure for a retail pharmacy to
challenge a listed maximum allowable cost;
(2) respond to a challenge under that procedure not
later than the 15th day after the date the challenge is made;
(3) if the challenge is successful, adjust the maximum
allowable cost effective on the date the challenge is resolved and
apply the adjustment to all retail pharmacies under the contract;
(4) if the challenge is denied, provide each reason
for the denial; and
(5) report every 90 days to the commission the total
number of challenges made and denied in the preceding 90-day period
to the maximum allowable cost for each medication the maximum
allowable cost of which was challenged during that period.
SECTION 2. Subchapter B, Chapter 1551, Insurance Code, is
amended by adding Section 1551.0671 to read as follows:
Sec. 1551.0671. TRANSPARENCY IN PHARMACY BENEFIT
MANAGEMENT. (a) In this section, "maximum allowable cost" means a
maximum reimbursement amount for a group of therapeutically and
pharmaceutically equivalent multiple source medications.
(b) Each contract to provide pharmacy benefit manager
services must require the pharmacy benefit manager to:
(1) establish:
(A) a method of calculating, updating, and
revising a maximum allowable cost for each covered medication;
(B) intervals not to exceed seven days for
updating or revising the maximum allowable cost for each medication
on the maximum allowable cost list; and
(C) for that contract a single maximum allowable
cost list that uniformly serves as a basis for the calculation of
reimbursement amounts for pharmacy claims covered by the group
benefits program;
(2) develop and maintain a public Internet website and
post and maintain on the website the information required by
Subdivision (1)(C);
(3) notify each retail pharmacy affected by a
modification of a maximum allowable cost of the modification on the
date of the modification;
(4) disclose the data sources from which the pharmacy
benefit manager obtains pricing data used in establishing a maximum
allowable cost; and
(5) not less frequently than once a week, notify each
retail pharmacy affected by the pharmacy benefit manager's
substitution or deletion of, or addition to, a data source from
which the pharmacy benefit manager obtains pricing data used in
establishing a maximum allowable cost of the substitution,
deletion, or addition.
(c) A contract to provide pharmacy benefit manager services
must require the pharmacy benefit manager to provide to the board of
trustees the information described by Subsections (b)(1)(B) and
(C). On request, the board of trustees shall provide the
information to a pharmacist or pharmacy.
(d) A contract to provide pharmacy benefit manager services
must require that each medication on a maximum allowable cost list:
(1) is listed as "A" or "B" rated in the most recent
version of the United States Food and Drug Administration's Drug
Products with Therapeutic Equivalence Evaluations, also known as
the Orange Book;
(2) is rated "NR" or "NA" by Medi-Span; or
(3) has a similar rating by a nationally recognized
reference.
(e) A contract to provide pharmacy benefit manager services
must require the pharmacy benefit manager to:
(1) provide a procedure for a retail pharmacy to
challenge a listed maximum allowable cost;
(2) respond to a challenge under that procedure not
later than the 15th day after the date the challenge is made;
(3) if the challenge is successful, adjust the maximum
allowable cost effective on the date the challenge is resolved and
apply the adjustment to all retail pharmacies under the contract;
(4) if the challenge is denied, provide each reason
for the denial; and
(5) report every 90 days to the board of trustees the
total number of challenges made and denied in the preceding 90-day
period to the maximum allowable cost for each medication the
maximum allowable cost of which was challenged during that period.
SECTION 3. Subchapter C, Chapter 1575, Insurance Code, is
amended by adding Section 1575.111 to read as follows:
Sec. 1575.111. TRANSPARENCY IN PHARMACY BENEFIT
MANAGEMENT. (a) In this section, "maximum allowable cost" means a
maximum reimbursement amount for a group of therapeutically and
pharmaceutically equivalent multiple source medications.
(b) Each contract to provide pharmacy benefit manager
services must require the pharmacy benefit manager to:
(1) establish:
(A) a method of calculating, updating, and
revising a maximum allowable cost for each covered medication;
(B) intervals not to exceed seven days for
updating or revising the maximum allowable cost for each medication
on the maximum allowable cost list; and
(C) for that contract a single maximum allowable
cost list that uniformly serves as a basis for the calculation of
reimbursement amounts for pharmacy claims covered by the group
program;
(2) develop and maintain a public Internet website and
post and maintain on the website the information required by
Subdivision (1)(C);
(3) notify each retail pharmacy affected by a
modification of a maximum allowable cost of the modification on the
date of the modification;
(4) disclose the data sources from which the pharmacy
benefit manager obtains pricing data used in establishing a maximum
allowable cost; and
(5) not less frequently than once a week, notify each
retail pharmacy affected by the pharmacy benefit manager's
substitution or deletion of, or addition to, a data source from
which the pharmacy benefit manager obtains pricing data used in
establishing a maximum allowable cost of the substitution,
deletion, or addition.
(c) A contract to provide pharmacy benefit manager services
must require the pharmacy benefit manager to provide to the trustee
the information described by Subsections (b)(1)(B) and (C). On
request, the trustee shall provide the information to a pharmacist
or pharmacy.
(d) A contract to provide pharmacy benefit manager services
must require that each medication on a maximum allowable cost list:
(1) is listed as "A" or "B" rated in the most recent
version of the United States Food and Drug Administration's Drug
Products with Therapeutic Equivalence Evaluations, also known as
the Orange Book;
(2) is rated "NR" or "NA" by Medi-Span; or
(3) has a similar rating by a nationally recognized
reference.
(e) A contract to provide pharmacy benefit manager services
must require the pharmacy benefit manager to:
(1) provide a procedure for a retail pharmacy to
challenge a listed maximum allowable cost;
(2) respond to a challenge under that procedure not
later than the 15th day after the date the challenge is made;
(3) if the challenge is successful, adjust the maximum
allowable cost effective on the date the challenge is resolved and
apply the adjustment to all retail pharmacies under the contract;
(4) if the challenge is denied, provide each reason
for the denial; and
(5) report every 90 days to the trustee the total
number of challenges made and denied in the preceding 90-day period
to the maximum allowable cost for each medication the maximum
allowable cost of which was challenged during that period.
SECTION 4. Subchapter B, Chapter 1579, Insurance Code, is
amended by adding Section 1579.058 to read as follows:
Sec. 1579.058. TRANSPARENCY IN PHARMACY BENEFIT
MANAGEMENT. (a) In this section, "maximum allowable cost" means a
maximum reimbursement amount for a group of therapeutically and
pharmaceutically equivalent multiple source medications.
(b) Each contract to provide pharmacy benefit manager
services must require the pharmacy benefit manager to:
(1) establish:
(A) a method of calculating, updating, and
revising a maximum allowable cost for each covered medication;
(B) intervals not to exceed seven days for
updating or revising the maximum allowable cost for each medication
on the maximum allowable cost list; and
(C) for that contract a single maximum allowable
cost list that uniformly serves as a basis for the calculation of
reimbursement amounts for pharmacy claims covered by a health
coverage plan;
(2) develop and maintain a public Internet website and
post and maintain on the website the information required by
Subdivision (1)(C);
(3) notify each retail pharmacy affected by a
modification of a maximum allowable cost of the modification on the
date of the modification;
(4) disclose the data sources from which the pharmacy
benefit manager obtains pricing data used in establishing a maximum
allowable cost; and
(5) not less frequently than once a week, notify each
retail pharmacy affected by the pharmacy benefit manager's
substitution or deletion of, or addition to, a data source from
which the pharmacy benefit manager obtains pricing data used in
establishing a maximum allowable cost of the substitution,
deletion, or addition.
(c) A contract to provide pharmacy benefit manager services
must require the pharmacy benefit manager to provide to the trustee
the information described by Subsections (b)(1)(B) and (C). On
request, the trustee shall provide the information to a pharmacist
or pharmacy.
(d) A contract to provide pharmacy benefit manager services
must require that each medication on a maximum allowable cost list:
(1) is listed as "A" or "B" rated in the most recent
version of the United States Food and Drug Administration's Drug
Products with Therapeutic Equivalence Evaluations, also known as
the Orange Book;
(2) is rated "NR" or "NA" by Medi-Span; or
(3) has a similar rating by a nationally recognized
reference.
(e) A contract to provide pharmacy benefit manager services
must require the pharmacy benefit manager to:
(1) provide a procedure for a retail pharmacy to
challenge a listed maximum allowable cost;
(2) respond to a challenge under that procedure not
later than the 15th day after the date the challenge is made;
(3) if the challenge is successful, adjust the maximum
allowable cost effective on the date the challenge is resolved and
apply the adjustment to all retail pharmacies under the contract;
(4) if the challenge is denied, provide each reason
for the denial; and
(5) report every 90 days to the trustee the total
number of challenges made and denied in the preceding 90-day period
to the maximum allowable cost for each medication the maximum
allowable cost of which was challenged during that period.
SECTION 5. Subchapter B, Chapter 1601, Insurance Code, is
amended by adding Section 1601.065 to read as follows:
Sec. 1601.065. TRANSPARENCY IN PHARMACY BENEFIT
MANAGEMENT. (a) In this section, "maximum allowable cost" means a
maximum reimbursement amount for a group of therapeutically and
pharmaceutically equivalent multiple source medications.
(b) Each contract to provide pharmacy benefit manager
services must require the pharmacy benefit manager to:
(1) establish:
(A) a method of calculating, updating, and
revising a maximum allowable cost for each covered medication;
(B) intervals not to exceed seven days for
updating or revising the maximum allowable cost for each medication
on the maximum allowable cost list; and
(C) for that contract a single maximum allowable
cost list that uniformly serves as a basis for the calculation of
reimbursement amounts for pharmacy claims covered by the basic
coverage;
(2) develop and maintain a public Internet website and
post and maintain on the website the information required by
Subdivision (1)(C);
(3) notify each retail pharmacy affected by a
modification of a maximum allowable cost of the modification on the
date of the modification;
(4) disclose the data sources from which the pharmacy
benefit manager obtains pricing data used in establishing a maximum
allowable cost; and
(5) not less frequently than once a week, notify each
retail pharmacy affected by the pharmacy benefit manager's
substitution or deletion of, or addition to, a data source from
which the pharmacy benefit manager obtains pricing data used in
establishing a maximum allowable cost of the substitution,
deletion, or addition.
(c) A contract to provide pharmacy benefit manager services
must require the pharmacy benefit manager to provide to the
governing board of the system the information described by
Subsections (b)(1)(B) and (C). On request, the system shall
provide the information to a pharmacist or pharmacy.
(d) A contract to provide pharmacy benefit manager services
must require that each medication on a maximum allowable cost list:
(1) is listed as "A" or "B" rated in the most recent
version of the United States Food and Drug Administration's Drug
Products with Therapeutic Equivalence Evaluations, also known as
the Orange Book;
(2) is rated "NR" or "NA" by Medi-Span; or
(3) has a similar rating by a nationally recognized
reference.
(e) A contract to provide pharmacy benefit manager services
must require the pharmacy benefit manager to:
(1) provide a procedure for a retail pharmacy to
challenge a listed maximum allowable cost;
(2) respond to a challenge under that procedure not
later than the 15th day after the date the challenge is made;
(3) if the challenge is successful, adjust the maximum
allowable cost effective on the date the challenge is resolved and
apply the adjustment to all retail pharmacies under the contract;
(4) if the challenge is denied, provide each reason
for the denial; and
(5) report every 90 days to the system the total number
of challenges made and denied in the preceding 90-day period to the
maximum allowable cost for each medication the maximum allowable
cost of which was challenged during that period.
SECTION 6. Subchapter Y, Chapter 531, Government Code, and
Sections 1551.0671, 1575.111, 1579.058, and 1601.065, Insurance
Code, as added by this Act, apply only to a contract with a pharmacy
benefit manager entered into or renewed on or after the effective
date of this Act.
SECTION 7. This Act takes effect September 1, 2013.