Texas 2015 - 84th Regular

Texas Senate Bill SB332 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	By: Schwertner, et al. S.B. No. 332
2		-	(Hunter)
	1	+	S.B. No. 332
3	2
4	3
5		-	A BILL TO BE ENTITLED
6	4		AN ACT
7	5		relating to the use of maximum allowable cost lists related to
8	6		pharmacy benefits.
9	7		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	8		SECTION 1. Chapter 1369, Insurance Code, is amended by
11	9		adding Subchapter H to read as follows:
12	10		SUBCHAPTER H. MAXIMUM ALLOWABLE COST
13	11		Sec. 1369.351. DEFINITIONS. In this subchapter:
14	12		(1) "Health benefit plan" has the meaning assigned by
15	13		Section 1369.251, as added by Chapter 915 (H.B. 1358), Acts of the
16	14		83rd Legislature, Regular Session, 2013.
17	15		(2) "Pharmacy benefit manager" has the meaning
18	16		assigned by Section 4151.151.
19	17		Sec. 1369.352. CERTAIN BENEFITS EXCLUDED. This subchapter
20	18		does not apply to maximum allowable costs for pharmacy benefits
21	19		provided under:
22	20		(1) a Medicaid managed care program operated under
23	21		Chapter 533, Government Code;
24	22		(2) a Medicaid program operated under Chapter 32,
25	23		Human Resources Code;
26	24		(3) the child health plan program under Chapter 62,
27	25		Health and Safety Code;
28	26		(4) the health benefits plan for children under
29	27		Chapter 63, Health and Safety Code;
30	28		(5) a health benefit plan issued under Chapter 1551,
31	29		1575, 1579, or 1601; or
32	30		(6) a workers' compensation insurance policy or other
33	31		form of providing medical benefits under Title 5, Labor Code.
34	32		Sec. 1369.353. CRITERIA FOR DRUGS ON MAXIMUM ALLOWABLE COST
35	33		LISTS. A health benefit plan issuer or pharmacy benefit manager may
36	34		not include a drug on a maximum allowable cost list unless:
37	35		(1) the drug:
38	36		(A) has an "A" or "B" rating in the most recent
39	37		version of the United States Food and Drug Administration's
40	38		Approved Drug Products with Therapeutic Equivalence Evaluations,
41	39		also known as the Orange Book; or
42	40		(B) is rated "NR" or "NA" or has a similar rating
43	41		by a nationally recognized reference; and
44	42		(2) the drug is:
45	43		(A) generally available for purchase by
46	44		pharmacists and pharmacies in this state from a national or
47	45		regional wholesaler; and
48	46		(B) not obsolete.
49	47		Sec. 1369.354. FORMULATION OF MAXIMUM ALLOWABLE COSTS;
50	48		DISCLOSURES. (a) In formulating the maximum allowable cost price
51	49		for a drug, a health benefit plan issuer or pharmacy benefit manager
52	50		may only use the price of that drug and any drug listed as
53	51		therapeutically equivalent to that drug in the most recent version
54	52		of the United States Food and Drug Administration's Approved Drug
55	53		Products with Therapeutic Equivalence Evaluations, also known as
56	54		the Orange Book.
57	55		(b) Notwithstanding Subsection (a), if a therapeutically
58	56		equivalent generic drug is unavailable or has limited market
59	57		presence, a health benefit plan issuer or pharmacy benefit manager
60	58		may place on a maximum allowable cost list a drug that has:
61	59		(1) a "B" rating in the most recent version of the
62	60		United States Food and Drug Administration's Approved Drug Products
63	61		with Therapeutic Equivalence Evaluations, also known as the Orange
64	62		Book; or
65	63		(2) an "NR" or "NA" rating or a similar rating by a
66	64		nationally recognized reference.
67	65		(c) A health benefit plan issuer or pharmacy benefit manager
68	66		must, in accordance with Subsection (d), disclose to a pharmacist
69	67		or pharmacy the sources of the pricing data used in formulating
70	68		maximum allowable cost prices.
71	69		(d) The information described by Subsection (c) must be
72	70		disclosed:
73	71		(1) on the date the health benefit plan issuer or
74	72		pharmacy benefit manager enters into the contract with the
75	73		pharmacist or pharmacy; and
76	74		(2) after that contract date, on the request of the
77	75		pharmacist or pharmacy.
78	76		Sec. 1369.355. UPDATES. (a) A health benefit plan issuer
79	77		or pharmacy benefit manager shall establish a process that will in a
80	78		timely manner eliminate drugs from maximum allowable cost lists or
81	79		modify maximum allowable cost prices to remain consistent with
82	80		changes in pricing data used in formulating maximum allowable cost
83	81		prices and product availability.
84	82		(b) A health benefit plan issuer or pharmacy benefit manager
85	83		shall review and update maximum allowable cost price information
86	84		for each drug at least once every seven days to reflect any
87	85		modification of maximum allowable cost pricing.
88	86		Sec. 1369.356. ACCESS TO MAXIMUM ALLOWABLE COST LISTS. A
89	87		health benefit plan issuer or pharmacy benefit manager must provide
90	88		to each pharmacist or pharmacy under contract with the health
91	89		benefit plan issuer or pharmacy benefit manager a process to
92	90		readily access the maximum allowable cost list that applies to the
93	91		pharmacist or pharmacy.
94	92		Sec. 1369.357. APPEAL FROM MAXIMUM ALLOWABLE COST PRICE
95	93		DETERMINATION. (a) A health benefit plan issuer or pharmacy
96	94		benefit manager must provide in the contract with each pharmacist
97	95		or pharmacy a procedure for the pharmacist or pharmacy to appeal a
98	96		maximum allowable cost price of a drug on or before the 10th day
99	97		after the date a pharmacy benefit claim for the drug is made.
100	98		(b) The health benefit plan issuer or pharmacy benefit
101	99		manager shall respond to an appeal described by Subsection (a) in a
102	100		documented communication not later than the 10th day after the date
103	101		the appeal is received by the health benefit plan issuer or pharmacy
104	102		benefit manager.
105	103		(c) If the appeal is successful, the health benefit plan
106	104		issuer or pharmacy benefit manager shall:
107	105		(1) adjust the maximum allowable cost price that is
108	106		the subject of the appeal effective on the day after the date the
109	107		appeal is decided;
110	108		(2) apply the adjusted maximum allowable cost price to
111	109		all similarly situated pharmacists and pharmacies as determined by
112	110		the health benefit plan issuer or pharmacy benefit manager; and
113	111		(3) allow the pharmacist or pharmacy that succeeded in
114	112		the appeal to reverse and rebill the pharmacy benefit claim giving
115	113		rise to the appeal.
116	114		(d) If the appeal is not successful, the health benefit plan
117	115		issuer or pharmacy benefit manager shall disclose to the pharmacist
118	116		or pharmacy:
119	117		(1) each reason the appeal is denied; and
120	118		(2) the national drug code number from the national or
121	119		regional wholesalers from which the drug is generally available for
122	120		purchase by pharmacists and pharmacies in this state at the maximum
123	121		allowable cost price that is the subject of the appeal.
124	122		Sec. 1369.358. CONFIDENTIALITY OF MAXIMUM ALLOWABLE COST
125	123		LIST. A maximum allowable cost list that applies to a pharmacist or
126	124		pharmacy and is maintained by a health benefit plan issuer or
127	125		pharmacy benefit manager is confidential. This section may not be
128	126		construed to alter a health benefit plan issuer's or pharmacy
129	127		benefit manager's obligations under Section 1369.356.
130	128		Sec. 1369.359. WAIVER PROHIBITED. The provisions of this
131	129		subchapter may not be waived, voided, or nullified by contract.
132	130		Sec. 1369.360. REMEDIES NOT EXCLUSIVE. This subchapter may
133	131		not be construed to waive a remedy at law available to a pharmacist
134	132		or pharmacy.
135	133		Sec. 1369.361. ENFORCEMENT. The commissioner shall enforce
136	134		this subchapter.
137	135		Sec. 1369.362. LEGISLATIVE DECLARATION. It is the intent
138	136		of the legislature that, except with respect to the benefits
139	137		excluded under Section 1369.352, the requirements contained in this
140	138		subchapter apply to all health benefit plan issuers and pharmacy
141	139		benefit managers unless otherwise prohibited by federal law.
142	140		SECTION 2. This Act applies only to a contract between a
143	141		health benefit plan issuer or a pharmacy benefit manager and a
144	142		pharmacist or pharmacy entered into or renewed on or after January
145	143		1, 2016. A contract entered into or renewed before January 1, 2016,
146	144		is governed by the law as it existed immediately before the
147	145		effective date of this Act, and that law is continued in effect for
148	146		that purpose.
149	147		SECTION 3. This Act takes effect January 1, 2016.
	148	+	______________________________ ______________________________
	149	+	President of the Senate Speaker of the House
	150	+	I hereby certify that S.B. No. 332 passed the Senate on
	151	+	April 9, 2015, by the following vote: Yeas 31, Nays 0.
	152	+	______________________________
	153	+	Secretary of the Senate
	154	+	I hereby certify that S.B. No. 332 passed the House on
	155	+	May 23, 2015, by the following vote: Yeas 138, Nays 2, one
	156	+	present not voting.
	157	+	______________________________
	158	+	Chief Clerk of the House
	159	+	Approved:
	160	+	______________________________
	161	+	Date
	162	+	______________________________
	163	+	Governor