84R1613 PMO-F
By: Hunter H.B. No. 1770
A BILL TO BE ENTITLED
AN ACT
relating to access to pharmacists, pharmacies, and pharmaceutical
care under certain health benefit plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 1451, Insurance Code, is amended by
adding Subchapter K to read as follows:
SUBCHAPTER K. ACCESS TO PHARMACIES, PHARMACISTS, AND
PHARMACEUTICAL CARE
Sec. 1451.501. DEFINITIONS. In this subchapter:
(1) "Drug," "pharmaceutical care," "pharmacist,"
"pharmacy," and "prescription drug" have the meanings assigned by
Section 551.003, Occupations Code.
(2) "Enrollee" means an individual who is covered
under a health benefit plan, including a covered dependent.
(3) "Pharmacy benefit manager" has the meaning
assigned by Section 4151.151.
Sec. 1451.502. APPLICABILITY OF SUBCHAPTER. (a) Except as
provided by Section 1451.503, this subchapter applies only to a
health benefit plan that provides benefits for medical, surgical,
or other treatment expenses incurred as a result of a health
condition, an accident, sickness, or substance abuse, 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 by:
(1) an insurance company;
(2) a group hospital service corporation operating
under Chapter 842;
(3) a health maintenance organization operating under
Chapter 843;
(4) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844;
(5) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846;
(6) a stipulated premium company operating under
Chapter 884;
(7) a fraternal benefit society operating under
Chapter 885;
(8) a Lloyd's plan operating under Chapter 941; or
(9) an exchange operating under Chapter 942.
(b) Notwithstanding any provision in Chapter 1551, 1575,
1579, or 1601 or any other law, this chapter applies to health
benefit plan coverage provided under:
(1) Chapter 1551;
(2) Chapter 1575;
(3) Chapter 1579; and
(4) Chapter 1601.
(c) Notwithstanding Section 1501.251 or any other law, this
chapter applies to coverage under a small employer health benefit
plan subject to Chapter 1501.
Sec. 1451.503. EXCEPTION TO APPLICABILITY OF SUBCHAPTER.
This subchapter does not apply to a self-insured, self-funded, or
other employee welfare benefit plan that is exempt from state
regulation under the Employee Retirement Income Security Act of
1974 (29 U.S.C. Section 1001 et seq.).
Sec. 1451.504. SELECTION OF PHARMACIST AND PHARMACY. A
health benefit plan issuer or a pharmacy benefit manager
administering pharmacy benefits under a health benefit plan may
not:
(1) prohibit or limit an enrollee from selecting a
pharmacist or pharmacy of the enrollee's choice to furnish
prescription drugs or pharmaceutical care covered by the health
benefit plan; or
(2) interfere with an enrollee's selection of a
pharmacist or pharmacy to furnish prescription drugs or
pharmaceutical care covered by the health benefit plan.
Sec. 1451.505. PARTICIPATION OF PHARMACISTS AND
PHARMACIES. (a) Subject to Subsection (b), a health benefit plan
issuer or a pharmacy benefit manager administering pharmacy
benefits under a health benefit plan may not deny a pharmacist or
pharmacy the right to participate as a provider or preferred
provider, as applicable, under the health benefit plan if the
pharmacist or pharmacy agrees to:
(1) provide prescription drugs and pharmaceutical
care in accordance with the terms of the health benefit plan; and
(2) accept the administrative, financial, and
professional conditions that apply to pharmacists and pharmacies
who have been designated by the health benefit plan or the pharmacy
benefit manager as providers or preferred providers, as applicable,
under the health benefit plan.
(b) The conditions described by Subsection (a)(2) must be
applied uniformly to all pharmacists and pharmacies who have been
designated by the health benefit plan or the pharmacy benefit
manager as providers or preferred providers, as applicable, under
the health benefit plan.
Sec. 1451.506. MANDATORY PARTICIPATION PROHIBITED. A
health benefit plan issuer or a pharmacy benefit manager
administering pharmacy benefits under a health benefit plan may not
require a pharmacist or pharmacy to participate as a provider or
preferred provider under a health benefit plan as a condition of
participating as a provider or preferred provider under another
health benefit plan.
Sec. 1451.507. DOSAGE AND QUANTITY REQUIREMENTS. (a) A
health benefit plan issuer or a pharmacy benefit manager
administering pharmacy benefits under a health benefit plan may not
require an enrollee to obtain or request a specific quantity or
dosage supply of prescription drugs.
(b) Notwithstanding Subsection (a), an enrollee's physician
or other prescribing health care provider may prescribe
prescription drugs in a quantity or dosage supply the physician or
provider determines appropriate and that is in compliance with
state and federal statutes.
Sec. 1451.508. COST SAVING MEASURES ALLOWED. (a) Subject
to Subsection (b), this subchapter does not prohibit a health
benefit plan issuer or pharmacy benefit manager administering
pharmacy benefits under a health benefit plan from, in an effort to
achieve cost savings to the health benefit plan or the enrollee:
(1) limiting the quantity or dosage supply of a drug
covered under the plan; or
(2) providing a financial incentive to encourage an
enrollee or physician or other prescribing health care provider to
use certain drugs in certain quantities.
(b) The quantity or dosage limitations and the financial
incentives described by Subsection (a) must be applied or provided
uniformly to all pharmacists and pharmacies who have been
designated by the health benefit plan or pharmacy benefit manager
as providers or preferred providers, as applicable, under the
health benefit plan.
Sec. 1451.509. PHARMACY BENEFIT CARD PROGRAM. This
subchapter does not prohibit a health benefit plan issuer or
pharmacy benefit manager administering pharmacy benefits under a
health benefit plan from establishing or administering a pharmacy
benefit card program that is a "discount health care program" for
purposes of Chapter 562 that authorizes an enrollee to obtain
prescription drugs and pharmaceutical care from designated
providers.
Sec. 1451.510. APPLICATION AND RENEWAL FEES. This
subchapter does not prohibit a health benefit plan issuer or
pharmacy benefit manager administering pharmacy benefits under a
health benefit plan from establishing reasonable and uniform
application and renewal fees for a pharmacist or pharmacy to
participate as a provider or preferred provider, as applicable,
under the health benefit plan.
Sec. 1451.511. COVERAGE NOT REQUIRED. This subchapter does
not require a health benefit plan to provide coverage for drugs or
pharmaceutical care.
Sec. 1451.512. CONFLICTING CONTRACT PROVISION VOID. A
provision of a health benefit plan or of a contract with a pharmacy
benefit manager that conflicts with this subchapter is void to the
extent of the conflict.
Sec. 1451.513. INJUNCTIVE RELIEF. A pharmacist, pharmacy,
or enrollee adversely affected by a violation of this subchapter
may bring suit in district court for injunctive relief to enforce
this subchapter.
Sec. 1451.514. DEPARTMENT MONITORING. The commissioner
shall monitor health benefit plans and pharmacy benefit managers to
ensure compliance with this subchapter.
SECTION 2. Section 843.303(b), Insurance Code, is amended
to read as follows:
(b) Unless otherwise limited by Subchapter K, Chapter 1451
[Article 21.52B], this section does not prohibit a health
maintenance organization from rejecting an initial application
from a physician or provider based on the determination that the
plan has sufficient qualified physicians or providers.
SECTION 3. Section 843.304(c), Insurance Code, is amended
to read as follows:
(c) This section does not require that a health maintenance
organization:
(1) use a particular type of provider in its
operation;
(2) accept each provider of a category or type, except
as provided by Subchapter K, Chapter 1451 [Article 21.52B]; or
(3) contract directly with providers of a particular
category or type.
SECTION 4. Article 21.52B, Insurance Code, is repealed.
SECTION 5. This Act applies only to a health benefit plan
that is delivered, issued for delivery, or renewed on or after
January 1, 2016. A health benefit plan delivered, issued for
delivery, or renewed before January 1, 2016, is governed by the law
as it existed immediately before the effective date of this Act, and
that law is continued in effect for that purpose.
SECTION 6. This Act takes effect September 1, 2015.