By: Kolkhorst, et al. S.B. No. 2195
A BILL TO BE ENTITLED
AN ACT
relating to the relationship between pharmacists or pharmacies and
pharmacy benefit managers or health benefit plan issuers.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter D, Chapter 4151, Insurance Code, is
amended by adding Section 4151.155 to read as follows:
Sec. 4151.155. REDUCTION OF CERTAIN CLAIM PAYMENT AMOUNTS
PROHIBITED. (a) A pharmacy benefit manager may not directly or
indirectly reduce the amount of a claim payment to a pharmacist or
pharmacy after adjudication of the claim through the use of an
aggregated effective rate, a quality assurance program, other
direct or indirect remuneration fee, or otherwise, except in
accordance with an audit.
(b) Nothing in this section prohibits a pharmacy benefit
manager from increasing a claim payment amount after adjudication
of the claim.
(c) Notwithstanding any other law, this section applies to
the Medicaid managed care program operated under Chapter 533,
Government Code.
SECTION 2. Chapter 562, Occupations Code, is amended by
adding Subchapter E to read as follows:
SUBCHAPTER E. CONTRACTS WITH PHARMACISTS AND PHARMACIES
Sec. 562.201. DEFINITION. In this subchapter, "pharmacy
benefit manager" has the meaning assigned by Section 4151.151,
Insurance Code.
Sec. 562.202. 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, Insurance Code;
(3) a health maintenance organization operating under
Chapter 843, Insurance Code;
(4) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844, Insurance Code;
(5) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846, Insurance Code;
(6) a stipulated premium company operating under
Chapter 884, Insurance Code;
(7) a fraternal benefit society operating under
Chapter 885, Insurance Code;
(8) a Lloyd's plan operating under Chapter 941,
Insurance Code; or
(9) an exchange operating under Chapter 942, Insurance
Code.
(b) Notwithstanding any other law, this subchapter applies
to:
(1) a small employer health benefit plan subject to
Chapter 1501, Insurance Code, including coverage provided through a
health group cooperative under Subchapter B of that chapter;
(2) a standard health benefit plan issued under
Chapter 1507, Insurance Code;
(3) health benefits provided by or through a church
benefits board under Subchapter I, Chapter 22, Business
Organizations Code;
(4) a regional or local health care program operated
under Section 75.104, Health and Safety Code; and
(5) a self-funded health benefit plan sponsored by a
professional employer organization under Chapter 91, Labor Code.
Sec. 562.203. 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;
or
(2) prohibit a licensed pharmacist or pharmacy from
dispensing any drug, including a specialty drug, that may be
dispensed under the pharmacist's or pharmacy's license unless
applicable state or federal law prohibits the pharmacist or
pharmacy from dispensing the drug.
Sec. 562.204. RESTRICTIONS ON MAIL ORDER PHARMACY SERVICES.
A pharmacy benefit manager may not require an enrollee to use a mail
order pharmacy.
Sec. 562.205. DELIVERY OF DRUGS. Except in a case in which
the health benefit plan issuer or pharmacy benefit manager makes a
credible allegation of fraud against the pharmacist or pharmacy and
provides reasonable notice of the allegation and the basis of the
allegation to the pharmacist or pharmacy, 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 a drug to a patient on the
patient's request, to the extent permitted by law; or
(2) charging a shipping and handling fee to a patient
requesting a prescription be mailed or delivered if the pharmacist
or pharmacy discloses to the patient before the delivery:
(A) the fee that will be charged; and
(B) that the fee may not be reimbursable by the
health benefit plan issuer or pharmacy benefit manager.
Sec. 562.206. WAIVER PROHIBITED. The provisions of this
subchapter may not be waived, voided, or nullified by contract.
SECTION 3. The Health and Human Services Commission is
required to implement a provision of this Act only if the
legislature appropriates money to the commission specifically for
that purpose. If the legislature does not appropriate money
specifically for that purpose, the commission may, but is not
required to, implement a provision of this Act using other
appropriations that are available for that purpose.
SECTION 4. 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 5. This Act takes effect September 1, 2021.