84R4921 PMO-F
By: Hunter H.B. No. 1775
A BILL TO BE ENTITLED
AN ACT
relating to the use of maximum allowable cost lists related to
pharmacy benefits.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 1369, Insurance Code, is amended by
adding Subchapter H to read as follows:
SUBCHAPTER H. MAXIMUM ALLOWABLE COST
Sec. 1369.351. DEFINITIONS. In this subchapter:
(1) "Health benefit plan" has the meaning assigned by
Section 1369.251, as added by Chapter 915 (H.B. 1358), Acts of the
83rd Legislature, Regular Session, 2013.
(2) "Pharmacy benefit manager" has the meaning
assigned by Section 4151.151.
Sec. 1369.352. CRITERIA FOR DRUGS ON MAXIMUM ALLOWABLE COST
LISTS. A health benefit plan issuer or pharmacy benefit manager may
not include a drug on a maximum allowable cost list unless:
(1) the drug:
(A) is listed as "A" or "B" rated in the most
recent version of the United States Food and Drug Administration's
Approved Drug Products with Therapeutic Equivalence Evaluations,
also known as the Orange Book;
(B) is rated "NR" or "NA" by Medi-Span; or
(C) has a similar rating by a nationally
recognized reference; and
(2) the drug is:
(A) generally available for purchase by
pharmacists and pharmacies in this state from a national or
regional wholesaler; and
(B) not obsolete.
Sec. 1369.353. FORMULATION OF MAXIMUM ALLOWABLE COSTS;
DISCLOSURES. (a) In formulating the maximum allowable cost price
for a drug, a health benefit plan issuer or pharmacy benefit manager
may only use the price of that drug and any drug listed as
therapeutically equivalent to that drug in the most recent version
of the United States Food and Drug Administration's Approved Drug
Products with Therapeutic Equivalence Evaluations, also known as
the Orange Book.
(b) Notwithstanding Subsection (a), this section may not be
construed to prohibit a health benefit plan issuer or pharmacy
benefit manager from placing on a maximum allowable cost list a drug
that has an "NR" or "NA" rating by Medi-Span or a similar rating by a
nationally recognized reference.
(c) A health benefit plan issuer or pharmacy benefit manager
must, in accordance with Subsection (d), disclose to a pharmacist
or pharmacy the sources of the pricing data used in formulating
maximum allowable cost prices.
(d) The information described by Subsection (c) must be
disclosed:
(1) on the date the health benefit plan issuer or
pharmacy benefit manager enters into the contract with the
pharmacist or pharmacy; and
(2) after that contract date, on the request of the
pharmacist or pharmacy.
Sec. 1369.354. UPDATES. (a) A health benefit plan issuer or
pharmacy benefit manager shall establish a process that will in a
timely manner eliminate drugs from maximum allowable cost lists or
modify maximum allowable cost prices to remain consistent with
changes in pricing data used in formulating maximum allowable cost
prices and product availability.
(b) A health benefit plan issuer or pharmacy benefit manager
shall conduct a weekly review and update of the maximum allowable
cost price for each drug on the maximum allowable cost list.
Sec. 1369.355. ACCESS TO MAXIMUM ALLOWABLE COST LISTS. A
health benefit plan issuer or pharmacy benefit manager must provide
to each pharmacist or pharmacy under contract with the health
benefit plan issuer or pharmacy benefit manager convenient access
to the maximum allowable cost list that applies to the pharmacist or
pharmacy.
Sec. 1369.356. APPEAL FROM MAXIMUM ALLOWABLE COST PRICE
DETERMINATION. (a) A health benefit plan issuer or pharmacy
benefit manager must provide in the contract with each pharmacist
or pharmacy a procedure for the pharmacist or pharmacy to appeal a
maximum allowable cost price of a drug on or before the 14th day
after the date a pharmacy benefit claim for the drug is made.
(b) The health benefit plan issuer or pharmacy benefit
manager shall respond to an appeal described by Subsection (a) in a
documented communication not later than the 14th day after the date
the appeal is received by the health benefit plan issuer or pharmacy
benefit manager.
(c) If the appeal is successful, the health benefit plan
issuer or pharmacy benefit manager shall:
(1) adjust the maximum allowable cost price that is
the subject of the appeal effective on the date the appeal is
decided;
(2) apply the adjusted maximum allowable cost price to
all similarly situated pharmacists and pharmacies as determined by
the health benefit plan issuer or pharmacy benefit manager; and
(3) allow the pharmacist or pharmacy that succeeded in
the appeal to reverse and rebill the pharmacy benefit claim giving
rise to the appeal and any other claim based on the maximum
allowable cost price that is the subject of the appeal and that is
made after the date of the claim giving rise to the appeal.
(d) If the appeal is not successful, the health benefit plan
issuer or pharmacy benefit manager shall disclose to the pharmacist
or pharmacy:
(1) each reason the appeal is denied; and
(2) the national drug code number from the national or
regional wholesalers from which the drug is generally available
for purchase by pharmacists and pharmacies in this state at the
maximum allowable cost price that is the subject of the appeal.
Sec. 1369.357. CONFIDENTIALITY OF MAXIMUM ALLOWABLE COST
LIST. Except as provided by Section 1369.355, a maximum allowable
cost list that applies to a pharmacist or pharmacy and is maintained
by a health benefit plan issuer or pharmacy benefit manager is
confidential.
Sec. 1369.358. WAIVER PROHIBITED. The provisions of this
subchapter may not be waived, voided, or nullified by contract.
Sec. 1369.359. REMEDIES NOT EXCLUSIVE. This subchapter may
not be construed to waive a remedy at law available to a pharmacist
or pharmacy.
Sec. 1369.360. ENFORCEMENT. The commissioner shall enforce
this subchapter.
Sec. 1369.361. LEGISLATIVE DECLARATION. It is the intent
of the legislature that the requirements contained in this
subchapter apply to all health benefit plan issuers and pharmacy
benefit managers unless otherwise prohibited by federal law.
SECTION 2. This Act applies only to a contract between a
health benefit plan issuer or a pharmacy benefit manager and a
pharmacist or pharmacy entered into or renewed on or after January
1, 2016. A contract entered into 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 3. This Act takes effect January 1, 2016.