Texas 2015 - 84th Regular

Texas House Bill HB1775 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	84R4921 PMO-F
2	2	By: Hunter H.B. No. 1775
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to the use of maximum allowable cost lists related to
8	8	pharmacy benefits.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Chapter 1369, Insurance Code, is amended by
11	11	adding Subchapter H to read as follows:
12	12	SUBCHAPTER H. MAXIMUM ALLOWABLE COST
13	13	Sec. 1369.351. DEFINITIONS. In this subchapter:
14	14	(1) "Health benefit plan" has the meaning assigned by
15	15	Section 1369.251, as added by Chapter 915 (H.B. 1358), Acts of the
16	16	83rd Legislature, Regular Session, 2013.
17	17	(2) "Pharmacy benefit manager" has the meaning
18	18	assigned by Section 4151.151.
19	19	Sec. 1369.352. CRITERIA FOR DRUGS ON MAXIMUM ALLOWABLE COST
20	20	LISTS. A health benefit plan issuer or pharmacy benefit manager may
21	21	not include a drug on a maximum allowable cost list unless:
22	22	(1) the drug:
23	23	(A) is listed as "A" or "B" rated in the most
24	24	recent version of the United States Food and Drug Administration's
25	25	Approved Drug Products with Therapeutic Equivalence Evaluations,
26	26	also known as the Orange Book;
27	27	(B) is rated "NR" or "NA" by Medi-Span; or
28	28	(C) has a similar rating by a nationally
29	29	recognized reference; and
30	30	(2) the drug is:
31	31	(A) generally available for purchase by
32	32	pharmacists and pharmacies in this state from a national or
33	33	regional wholesaler; and
34	34	(B) not obsolete.
35	35	Sec. 1369.353. FORMULATION OF MAXIMUM ALLOWABLE COSTS;
36	36	DISCLOSURES. (a) In formulating the maximum allowable cost price
37	37	for a drug, a health benefit plan issuer or pharmacy benefit manager
38	38	may only use the price of that drug and any drug listed as
39	39	therapeutically equivalent to that drug in the most recent version
40	40	of the United States Food and Drug Administration's Approved Drug
41	41	Products with Therapeutic Equivalence Evaluations, also known as
42	42	the Orange Book.
43	43	(b) Notwithstanding Subsection (a), this section may not be
44	44	construed to prohibit a health benefit plan issuer or pharmacy
45	45	benefit manager from placing on a maximum allowable cost list a drug
46	46	that has an "NR" or "NA" rating by Medi-Span or a similar rating by a
47	47	nationally recognized reference.
48	48	(c) A health benefit plan issuer or pharmacy benefit manager
49	49	must, in accordance with Subsection (d), disclose to a pharmacist
50	50	or pharmacy the sources of the pricing data used in formulating
51	51	maximum allowable cost prices.
52	52	(d) The information described by Subsection (c) must be
53	53	disclosed:
54	54	(1) on the date the health benefit plan issuer or
55	55	pharmacy benefit manager enters into the contract with the
56	56	pharmacist or pharmacy; and
57	57	(2) after that contract date, on the request of the
58	58	pharmacist or pharmacy.
59	59	Sec. 1369.354. UPDATES. (a) A health benefit plan issuer or
60	60	pharmacy benefit manager shall establish a process that will in a
61	61	timely manner eliminate drugs from maximum allowable cost lists or
62	62	modify maximum allowable cost prices to remain consistent with
63	63	changes in pricing data used in formulating maximum allowable cost
64	64	prices and product availability.
65	65	(b) A health benefit plan issuer or pharmacy benefit manager
66	66	shall conduct a weekly review and update of the maximum allowable
67	67	cost price for each drug on the maximum allowable cost list.
68	68	Sec. 1369.355. ACCESS TO MAXIMUM ALLOWABLE COST LISTS. A
69	69	health benefit plan issuer or pharmacy benefit manager must provide
70	70	to each pharmacist or pharmacy under contract with the health
71	71	benefit plan issuer or pharmacy benefit manager convenient access
72	72	to the maximum allowable cost list that applies to the pharmacist or
73	73	pharmacy.
74	74	Sec. 1369.356. APPEAL FROM MAXIMUM ALLOWABLE COST PRICE
75	75	DETERMINATION. (a) A health benefit plan issuer or pharmacy
76	76	benefit manager must provide in the contract with each pharmacist
77	77	or pharmacy a procedure for the pharmacist or pharmacy to appeal a
78	78	maximum allowable cost price of a drug on or before the 14th day
79	79	after the date a pharmacy benefit claim for the drug is made.
80	80	(b) The health benefit plan issuer or pharmacy benefit
81	81	manager shall respond to an appeal described by Subsection (a) in a
82	82	documented communication not later than the 14th day after the date
83	83	the appeal is received by the health benefit plan issuer or pharmacy
84	84	benefit manager.
85	85	(c) If the appeal is successful, the health benefit plan
86	86	issuer or pharmacy benefit manager shall:
87	87	(1) adjust the maximum allowable cost price that is
88	88	the subject of the appeal effective on the date the appeal is
89	89	decided;
90	90	(2) apply the adjusted maximum allowable cost price to
91	91	all similarly situated pharmacists and pharmacies as determined by
92	92	the health benefit plan issuer or pharmacy benefit manager; and
93	93	(3) allow the pharmacist or pharmacy that succeeded in
94	94	the appeal to reverse and rebill the pharmacy benefit claim giving
95	95	rise to the appeal and any other claim based on the maximum
96	96	allowable cost price that is the subject of the appeal and that is
97	97	made after the date of the claim giving rise to the appeal.
98	98	(d) If the appeal is not successful, the health benefit plan
99	99	issuer or pharmacy benefit manager shall disclose to the pharmacist
100	100	or pharmacy:
101	101	(1) each reason the appeal is denied; and
102	102	(2) the national drug code number from the national or
103	103	regional wholesalers from which the drug is generally available
104	104	for purchase by pharmacists and pharmacies in this state at the
105	105	maximum allowable cost price that is the subject of the appeal.
106	106	Sec. 1369.357. CONFIDENTIALITY OF MAXIMUM ALLOWABLE COST
107	107	LIST. Except as provided by Section 1369.355, a maximum allowable
108	108	cost list that applies to a pharmacist or pharmacy and is maintained
109	109	by a health benefit plan issuer or pharmacy benefit manager is
110	110	confidential.
111	111	Sec. 1369.358. WAIVER PROHIBITED. The provisions of this
112	112	subchapter may not be waived, voided, or nullified by contract.
113	113	Sec. 1369.359. REMEDIES NOT EXCLUSIVE. This subchapter may
114	114	not be construed to waive a remedy at law available to a pharmacist
115	115	or pharmacy.
116	116	Sec. 1369.360. ENFORCEMENT. The commissioner shall enforce
117	117	this subchapter.
118	118	Sec. 1369.361. LEGISLATIVE DECLARATION. It is the intent
119	119	of the legislature that the requirements contained in this
120	120	subchapter apply to all health benefit plan issuers and pharmacy
121	121	benefit managers unless otherwise prohibited by federal law.
122	122	SECTION 2. This Act applies only to a contract between a
123	123	health benefit plan issuer or a pharmacy benefit manager and a
124	124	pharmacist or pharmacy entered into or renewed on or after January
125	125	1, 2016. A contract entered into or renewed before January 1, 2016,
126	126	is governed by the law as it existed immediately before the
127	127	effective date of this Act, and that law is continued in effect for
128	128	that purpose.
129	129	SECTION 3. This Act takes effect January 1, 2016.