Texas 2015 - 84th Regular

Texas House Bill HB778 Compare Versions

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

Old	New	Differences
1	1	84R1613 PMO-F
2	2	By: Bell H.B. No. 778
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to access to pharmacists, pharmacies, and pharmaceutical
8	8	care under certain health benefit plans.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Chapter 1451, Insurance Code, is amended by
11	11	adding Subchapter K to read as follows:
12	12	SUBCHAPTER K. ACCESS TO PHARMACIES, PHARMACISTS, AND
13	13	PHARMACEUTICAL CARE
14	14	Sec. 1451.501. DEFINITIONS. In this subchapter:
15	15	(1) "Drug," "pharmaceutical care," "pharmacist,"
16	16	"pharmacy," and "prescription drug" have the meanings assigned by
17	17	Section 551.003, Occupations Code.
18	18	(2) "Enrollee" means an individual who is covered
19	19	under a health benefit plan, including a covered dependent.
20	20	(3) "Pharmacy benefit manager" has the meaning
21	21	assigned by Section 4151.151.
22	22	Sec. 1451.502. APPLICABILITY OF SUBCHAPTER. (a) Except as
23	23	provided by Section 1451.503, this subchapter applies only to a
24	24	health benefit plan that provides benefits for medical, surgical,
25	25	or other treatment expenses incurred as a result of a health
26	26	condition, an accident, sickness, or substance abuse, including an
27	27	individual, group, blanket, or franchise insurance policy or
28	28	insurance agreement, a group hospital service contract, or an
29	29	individual or group evidence of coverage or similar coverage
30	30	document that is offered by:
31	31	(1) an insurance company;
32	32	(2) a group hospital service corporation operating
33	33	under Chapter 842;
34	34	(3) a health maintenance organization operating under
35	35	Chapter 843;
36	36	(4) an approved nonprofit health corporation that
37	37	holds a certificate of authority under Chapter 844;
38	38	(5) a multiple employer welfare arrangement that holds
39	39	a certificate of authority under Chapter 846;
40	40	(6) a stipulated premium company operating under
41	41	Chapter 884;
42	42	(7) a fraternal benefit society operating under
43	43	Chapter 885;
44	44	(8) a Lloyd's plan operating under Chapter 941; or
45	45	(9) an exchange operating under Chapter 942.
46	46	(b) Notwithstanding any provision in Chapter 1551, 1575,
47	47	1579, or 1601 or any other law, this chapter applies to health
48	48	benefit plan coverage provided under:
49	49	(1) Chapter 1551;
50	50	(2) Chapter 1575;
51	51	(3) Chapter 1579; and
52	52	(4) Chapter 1601.
53	53	(c) Notwithstanding Section 1501.251 or any other law, this
54	54	chapter applies to coverage under a small employer health benefit
55	55	plan subject to Chapter 1501.
56	56	Sec. 1451.503. EXCEPTION TO APPLICABILITY OF SUBCHAPTER.
57	57	This subchapter does not apply to a self-insured, self-funded, or
58	58	other employee welfare benefit plan that is exempt from state
59	59	regulation under the Employee Retirement Income Security Act of
60	60	1974 (29 U.S.C. Section 1001 et seq.).
61	61	Sec. 1451.504. SELECTION OF PHARMACIST AND PHARMACY. A
62	62	health benefit plan issuer or a pharmacy benefit manager
63	63	administering pharmacy benefits under a health benefit plan may
64	64	not:
65	65	(1) prohibit or limit an enrollee from selecting a
66	66	pharmacist or pharmacy of the enrollee's choice to furnish
67	67	prescription drugs or pharmaceutical care covered by the health
68	68	benefit plan; or
69	69	(2) interfere with an enrollee's selection of a
70	70	pharmacist or pharmacy to furnish prescription drugs or
71	71	pharmaceutical care covered by the health benefit plan.
72	72	Sec. 1451.505. PARTICIPATION OF PHARMACISTS AND
73	73	PHARMACIES. (a) Subject to Subsection (b), a health benefit plan
74	74	issuer or a pharmacy benefit manager administering pharmacy
75	75	benefits under a health benefit plan may not deny a pharmacist or
76	76	pharmacy the right to participate as a provider or preferred
77	77	provider, as applicable, under the health benefit plan if the
78	78	pharmacist or pharmacy agrees to:
79	79	(1) provide prescription drugs and pharmaceutical
80	80	care in accordance with the terms of the health benefit plan; and
81	81	(2) accept the administrative, financial, and
82	82	professional conditions that apply to pharmacists and pharmacies
83	83	who have been designated by the health benefit plan or the pharmacy
84	84	benefit manager as providers or preferred providers, as applicable,
85	85	under the health benefit plan.
86	86	(b) The conditions described by Subsection (a)(2) must be
87	87	applied uniformly to all pharmacists and pharmacies who have been
88	88	designated by the health benefit plan or the pharmacy benefit
89	89	manager as providers or preferred providers, as applicable, under
90	90	the health benefit plan.
91	91	Sec. 1451.506. MANDATORY PARTICIPATION PROHIBITED. A
92	92	health benefit plan issuer or a pharmacy benefit manager
93	93	administering pharmacy benefits under a health benefit plan may not
94	94	require a pharmacist or pharmacy to participate as a provider or
95	95	preferred provider under a health benefit plan as a condition of
96	96	participating as a provider or preferred provider under another
97	97	health benefit plan.
98	98	Sec. 1451.507. DOSAGE AND QUANTITY REQUIREMENTS. (a) A
99	99	health benefit plan issuer or a pharmacy benefit manager
100	100	administering pharmacy benefits under a health benefit plan may not
101	101	require an enrollee to obtain or request a specific quantity or
102	102	dosage supply of prescription drugs.
103	103	(b) Notwithstanding Subsection (a), an enrollee's physician
104	104	or other prescribing health care provider may prescribe
105	105	prescription drugs in a quantity or dosage supply the physician or
106	106	provider determines appropriate and that is in compliance with
107	107	state and federal statutes.
108	108	Sec. 1451.508. COST SAVING MEASURES ALLOWED. (a) Subject
109	109	to Subsection (b), this subchapter does not prohibit a health
110	110	benefit plan issuer or pharmacy benefit manager administering
111	111	pharmacy benefits under a health benefit plan from, in an effort to
112	112	achieve cost savings to the health benefit plan or the enrollee:
113	113	(1) limiting the quantity or dosage supply of a drug
114	114	covered under the plan; or
115	115	(2) providing a financial incentive to encourage an
116	116	enrollee or physician or other prescribing health care provider to
117	117	use certain drugs in certain quantities.
118	118	(b) The quantity or dosage limitations and the financial
119	119	incentives described by Subsection (a) must be applied or provided
120	120	uniformly to all pharmacists and pharmacies who have been
121	121	designated by the health benefit plan or pharmacy benefit manager
122	122	as providers or preferred providers, as applicable, under the
123	123	health benefit plan.
124	124	Sec. 1451.509. PHARMACY BENEFIT CARD PROGRAM. This
125	125	subchapter does not prohibit a health benefit plan issuer or
126	126	pharmacy benefit manager administering pharmacy benefits under a
127	127	health benefit plan from establishing or administering a pharmacy
128	128	benefit card program that is a "discount health care program" for
129	129	purposes of Chapter 562 that authorizes an enrollee to obtain
130	130	prescription drugs and pharmaceutical care from designated
131	131	providers.
132	132	Sec. 1451.510. APPLICATION AND RENEWAL FEES. This
133	133	subchapter does not prohibit a health benefit plan issuer or
134	134	pharmacy benefit manager administering pharmacy benefits under a
135	135	health benefit plan from establishing reasonable and uniform
136	136	application and renewal fees for a pharmacist or pharmacy to
137	137	participate as a provider or preferred provider, as applicable,
138	138	under the health benefit plan.
139	139	Sec. 1451.511. COVERAGE NOT REQUIRED. This subchapter does
140	140	not require a health benefit plan to provide coverage for drugs or
141	141	pharmaceutical care.
142	142	Sec. 1451.512. CONFLICTING CONTRACT PROVISION VOID. A
143	143	provision of a health benefit plan or of a contract with a pharmacy
144	144	benefit manager that conflicts with this subchapter is void to the
145	145	extent of the conflict.
146	146	Sec. 1451.513. INJUNCTIVE RELIEF. A pharmacist, pharmacy,
147	147	or enrollee adversely affected by a violation of this subchapter
148	148	may bring suit in district court for injunctive relief to enforce
149	149	this subchapter.
150	150	Sec. 1451.514. DEPARTMENT MONITORING. The commissioner
151	151	shall monitor health benefit plans and pharmacy benefit managers to
152	152	ensure compliance with this subchapter.
153	153	SECTION 2. Section 843.303(b), Insurance Code, is amended
154	154	to read as follows:
155	155	(b) Unless otherwise limited by Subchapter K, Chapter 1451
156	156	[Article 21.52B], this section does not prohibit a health
157	157	maintenance organization from rejecting an initial application
158	158	from a physician or provider based on the determination that the
159	159	plan has sufficient qualified physicians or providers.
160	160	SECTION 3. Section 843.304(c), Insurance Code, is amended
161	161	to read as follows:
162	162	(c) This section does not require that a health maintenance
163	163	organization:
164	164	(1) use a particular type of provider in its
165	165	operation;
166	166	(2) accept each provider of a category or type, except
167	167	as provided by Subchapter K, Chapter 1451 [Article 21.52B]; or
168	168	(3) contract directly with providers of a particular
169	169	category or type.
170	170	SECTION 4. Article 21.52B, Insurance Code, is repealed.
171	171	SECTION 5. This Act applies only to a health benefit plan
172	172	that is delivered, issued for delivery, or renewed on or after
173	173	January 1, 2016. A health benefit plan delivered, issued for
174	174	delivery, or renewed before January 1, 2016, is governed by the law
175	175	as it existed immediately before the effective date of this Act, and
176	176	that law is continued in effect for that purpose.
177	177	SECTION 6. This Act takes effect September 1, 2015.