86R2805 JES-F
By: Lucio III H.B. No. 2817
A BILL TO BE ENTITLED
AN ACT
relating to the contractual relationship between a pharmacist or
pharmacy and a health benefit plan issuer or pharmacy benefit
manager.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 1369, Insurance Code, is amended by
adding Subchapter K to read as follows:
SUBCHAPTER K. CONTRACTS WITH PHARMACISTS AND PHARMACIES
Sec. 1369.501. DEFINITIONS. In this subchapter:
(1) "Pharmacy benefit manager" means a person, other
than a pharmacist or pharmacy, who acts as an administrator in
connection with pharmacy benefits.
(2) "Pharmacy services administrative organization"
means an entity that contracts with a pharmacist or pharmacy to
conduct on behalf of the pharmacist or pharmacy the pharmacist's or
pharmacy's business with a third-party payor, including a pharmacy
benefit manager, in connection with pharmacy benefits and to assist
the pharmacist or pharmacy by providing administrative services,
including negotiating, executing, and administering a contract
with a third-party payor and communicating with the third-party
payor in connection with a contract or pharmacy benefits.
Sec. 1369.502. APPLICABILITY OF SUBCHAPTER. (a) This
subchapter applies only to a health benefit plan that provides
benefits for medical or surgical expenses incurred as a result of a
health condition, accident, or sickness, 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 other law, this chapter applies to:
(1) a small employer health benefit plan subject to
Chapter 1501, including coverage provided through a health group
cooperative under Subchapter B of that chapter;
(2) a standard health benefit plan issued under
Chapter 1507;
(3) health benefits provided by or through a church
benefits board under Subchapter I, Chapter 22, Business
Organizations Code;
(4) group health coverage made available by a school
district in accordance with Section 22.004, Education Code;
(5) a regional or local health care program operated
under Section 75.104, Health and Safety Code;
(6) a self-funded health benefit plan sponsored by a
professional employer organization under Chapter 91, Labor Code;
(7) county employee group health benefits provided
under Chapter 157, Local Government Code; and
(8) health and accident coverage provided by a risk
pool created under Chapter 172, Local Government Code.
Sec. 1369.503. PERFORMANCE MEASURES AND RELATED FEES. (a)
A health benefit plan issuer or pharmacy benefit manager that
establishes a contractual pharmacy performance measure or pay for
performance pharmacy network shall evaluate the performance of
pharmacists or pharmacies for purposes of that measure or network
using a nationally recognized performance information management
tool that provides standardized, benchmarked data to improve
pharmacy performance.
(b) A health benefit plan issuer or pharmacy benefit manager
may not directly or indirectly charge or hold a pharmacist or
pharmacy responsible for a fee if:
(1) the pharmacist or pharmacy uses the performance
information management tool described by Subsection (a) to produce
a score or metric for patient care; and
(2) the score or metric is within the criteria
identified by the health benefit plan issuer or pharmacy benefit
manager using the data provided by the performance information
management tool.
(c) If a health benefit plan issuer or pharmacy benefit
manager imposes a fee on a pharmacist or pharmacy based on a score
or metric produced by the performance information management tool
described by Subsection (a), the health benefit plan issuer or
pharmacy benefit manager:
(1) may recover the fee as an offset against the
professional dispensing fee owed under the contract with the
pharmacist or pharmacy; and
(2) may not recover the fee as an offset against any
other amount owed to the pharmacist or pharmacy under the contract.
Sec. 1369.504. DISCLOSURE OF PHARMACY SERVICES
ADMINISTRATIVE ORGANIZATION CONTRACT. A pharmacist or pharmacy
that is a member of a pharmacy services administrative organization
that enters into a contract with a health benefit plan issuer or
pharmacy benefit manager on the pharmacist's or pharmacy's behalf
is entitled to receive a copy of the contract.
Sec. 1369.505. DELIVERY OF DRUGS. A health benefit plan
issuer or pharmacy benefit manager may not as a condition of a
contract with a pharmacist or pharmacy prohibit the pharmacist or
pharmacy from:
(1) mailing or delivering drugs to a patient as an
ancillary service of the pharmacist or pharmacy as otherwise
allowed by law; or
(2) charging a shipping and handling fee to a patient
requesting a prescription be mailed or delivered.
Sec. 1369.506. PROFESSIONAL STANDARDS AND SCOPE OF PRACTICE
REQUIREMENTS. A health benefit plan issuer or pharmacy benefit
manager may not as a condition of a contract with a pharmacist or
pharmacy:
(1) require pharmacist or pharmacy accreditation
standards or recertification requirements inconsistent with, more
stringent than, or in addition to federal and state requirements
for licensure as a pharmacist or pharmacy in this state; or
(2) prohibit a licensed pharmacist or pharmacy from
dispensing any drug that may be dispensed under the pharmacist's or
pharmacy's license.
Sec. 1369.507. WAIVER PROHIBITED. The provisions of this
subchapter may not be waived, voided, or nullified by contract.
Sec. 1369.508. UNFAIR OR DECEPTIVE ACT OR PRACTICE. A
violation of this subchapter by a health benefit plan issuer or
pharmacy benefit manager is an unfair or deceptive act or practice
in the business of insurance under Chapter 541.
SECTION 2. The change in law made by this Act applies only
to a contract entered into or renewed on or after the effective date
of this Act. A contract entered into or renewed before the
effective date of this Act 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 September 1, 2019.