Texas 2021 - 87th Regular

Texas Senate Bill SB528 Compare Versions

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

Old	New	Differences
1	1	87R3564 JES-F
2	2	By: Hughes, et al. S.B. No. 528
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to the contractual relationship between a pharmacist or
8	8	pharmacy and a health benefit plan issuer or pharmacy benefit
9	9	manager.
10	10	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
11	11	SECTION 1. Chapter 1369, Insurance Code, is amended by
12	12	adding Subchapter L to read as follows:
13	13	SUBCHAPTER L. CONTRACTS WITH PHARMACISTS AND PHARMACIES
14	14	Sec. 1369.551. DEFINITIONS. In this subchapter:
15	15	(1) "Pharmacy benefit manager" has the meaning
16	16	assigned by Section 4151.151.
17	17	(2) "Pharmacy benefit network" means a network of
18	18	pharmacies that have contracted with a pharmacy benefit manager to
19	19	provide pharmacist services to enrollees.
20	20	(3) "Pharmacy services administrative organization"
21	21	means an entity that contracts with a pharmacist or pharmacy to
22	22	conduct on behalf of the pharmacist or pharmacy the pharmacist's or
23	23	pharmacy's business with a third-party payor, including a pharmacy
24	24	benefit manager, in connection with pharmacy benefits and to assist
25	25	the pharmacist or pharmacy by providing administrative services,
26	26	including negotiating, executing, and administering a contract
27	27	with a third-party payor and communicating with the third-party
28	28	payor in connection with a contract or pharmacy benefits.
29	29	Sec. 1369.552. APPLICABILITY OF SUBCHAPTER. (a) This
30	30	subchapter applies only to a health benefit plan that provides
31	31	benefits for medical or surgical expenses incurred as a result of a
32	32	health condition, accident, or sickness, including an individual,
33	33	group, blanket, or franchise insurance policy or insurance
34	34	agreement, a group hospital service contract, or an individual or
35	35	group evidence of coverage or similar coverage document that is
36	36	offered by:
37	37	(1) an insurance company;
38	38	(2) a group hospital service corporation operating
39	39	under Chapter 842;
40	40	(3) a health maintenance organization operating under
41	41	Chapter 843;
42	42	(4) an approved nonprofit health corporation that
43	43	holds a certificate of authority under Chapter 844;
44	44	(5) a multiple employer welfare arrangement that holds
45	45	a certificate of authority under Chapter 846;
46	46	(6) a stipulated premium company operating under
47	47	Chapter 884;
48	48	(7) a fraternal benefit society operating under
49	49	Chapter 885;
50	50	(8) a Lloyd's plan operating under Chapter 941; or
51	51	(9) an exchange operating under Chapter 942.
52	52	(b) Notwithstanding any other law, this subchapter applies
53	53	to:
54	54	(1) a small employer health benefit plan subject to
55	55	Chapter 1501, including coverage provided through a health group
56	56	cooperative under Subchapter B of that chapter;
57	57	(2) a standard health benefit plan issued under
58	58	Chapter 1507;
59	59	(3) health benefits provided by or through a church
60	60	benefits board under Subchapter I, Chapter 22, Business
61	61	Organizations Code;
62	62	(4) group health coverage made available by a school
63	63	district in accordance with Section 22.004, Education Code;
64	64	(5) a regional or local health care program operated
65	65	under Section 75.104, Health and Safety Code; and
66	66	(6) a self-funded health benefit plan sponsored by a
67	67	professional employer organization under Chapter 91, Labor Code.
68	68	(c) This subchapter does not apply to an issuer or provider
69	69	of health benefits under or a pharmacy benefit manager
70	70	administering pharmacy benefits under a workers' compensation
71	71	insurance policy or other form of providing medical benefits under
72	72	Title 5, Labor Code.
73	73	Sec. 1369.553. REDUCTION OF CERTAIN CLAIM PAYMENT AMOUNTS
74	74	PROHIBITED. (a) A health benefit plan issuer or pharmacy benefit
75	75	manager may not directly or indirectly reduce the amount of a claim
76	76	payment to a pharmacist or pharmacy after adjudication of the claim
77	77	through the use of an aggregated effective rate, quality assurance
78	78	program, other direct or indirect remuneration fee, or otherwise,
79	79	except:
80	80	(1) in accordance with an audit performed under
81	81	Subchapter F; or
82	82	(2) by mutual agreement of the parties under a
83	83	pharmacy benefit network contract under which the health benefit
84	84	plan issuer or pharmacy benefit manager does not require as a
85	85	condition of the pharmacy benefit network contract or of
86	86	participation in the pharmacy benefit network that a pharmacist or
87	87	pharmacy agree to allow the health benefit plan issuer or pharmacy
88	88	benefit manager to reduce the amount of a claim payment to the
89	89	pharmacist or pharmacy after adjudication of the claim.
90	90	(b) Nothing in this section prohibits a health benefit plan
91	91	issuer or pharmacy benefit manager from increasing a claim payment
92	92	amount after adjudication of the claim.
93	93	Sec. 1369.554. REIMBURSEMENT OF AFFILIATED AND
94	94	NONAFFILIATED PHARMACISTS AND PHARMACIES. (a) In this section:
95	95	(1) "Affiliated pharmacist or pharmacy" means a
96	96	pharmacist or pharmacy that directly, or indirectly through one or
97	97	more intermediaries, controls or is controlled by, or is under
98	98	common control with, a pharmacy benefit manager.
99	99	(2) "Nonaffiliated pharmacist or pharmacy" means a
100	100	pharmacist or pharmacy that does not directly, or indirectly
101	101	through one or more intermediaries, control and is not controlled
102	102	by or under common control with a pharmacy benefit manager.
103	103	(b) A pharmacy benefit manager may not pay an affiliated
104	104	pharmacist or pharmacy a reimbursement amount that is more than the
105	105	amount the pharmacy benefit manager pays a nonaffiliated pharmacist
106	106	or pharmacy for the same pharmacist service.
107	107	Sec. 1369.555. NETWORK CONTRACT FEE SCHEDULE. A pharmacy
108	108	benefit network contract must specify or reference a separate fee
109	109	schedule. Unless otherwise available in the contract, the fee
110	110	schedule must be provided electronically in an easily accessible
111	111	and complete spreadsheet format and, on request, in writing to each
112	112	contracted pharmacist and pharmacy. The fee schedule must
113	113	describe:
114	114	(1) specific services or procedures that the
115	115	pharmacist or pharmacy may deliver and the amount of the
116	116	corresponding payment;
117	117	(2) a methodology for calculating the amount of the
118	118	payment based on a published fee schedule; or
119	119	(3) any other reasonable manner that provides an
120	120	ascertainable amount for payment for services.
121	121	Sec. 1369.556. DISCLOSURE OF PHARMACY SERVICES
122	122	ADMINISTRATIVE ORGANIZATION CONTRACT. A pharmacist or pharmacy
123	123	that is a member of a pharmacy services administrative organization
124	124	that enters into a contract with a health benefit plan issuer or
125	125	pharmacy benefit manager on the pharmacist's or pharmacy's behalf
126	126	is entitled to receive from the pharmacy services administrative
127	127	organization a copy of the contract provisions applicable to the
128	128	pharmacist or pharmacy, including each provision relating to the
129	129	pharmacist's or pharmacy's rights and obligations under the
130	130	contract.
131	131	Sec. 1369.557. DELIVERY OF DRUGS. (a) Except in a case in
132	132	which the health benefit plan issuer or pharmacy benefit manager
133	133	makes a credible allegation of fraud against the pharmacist or
134	134	pharmacy and provides reasonable notice of the allegation and the
135	135	basis of the allegation to the pharmacist or pharmacy, a health
136	136	benefit plan issuer or pharmacy benefit manager may not as a
137	137	condition of a contract with a pharmacist or pharmacy prohibit the
138	138	pharmacist or pharmacy from:
139	139	(1) mailing or delivering a drug to a patient on the
140	140	patient's request, to the extent permitted by law; or
141	141	(2) charging a shipping and handling fee to a patient
142	142	requesting a prescription be mailed or delivered if the pharmacist
143	143	or pharmacy discloses to the patient before the delivery:
144	144	(A) the fee that will be charged; and
145	145	(B) that the fee may not be reimbursable by the
146	146	health benefit plan issuer or pharmacy benefit manager.
147	147	(b) A pharmacist or pharmacy may not charge a health benefit
148	148	plan issuer or pharmacy benefit manager for the delivery of a
149	149	prescription drug as described by this section unless the charge is
150	150	specifically agreed to by the health benefit plan issuer or
151	151	pharmacy benefit manager.
152	152	(c) Notwithstanding Subsection (a), a health benefit plan
153	153	issuer or pharmacy benefit manager may as a condition of contract
154	154	prohibit a pharmacist or pharmacy from mailing the drugs for more
155	155	than 25 percent of the claims the pharmacist or pharmacy submits to
156	156	the health benefit plan issuer or pharmacy benefit manager during a
157	157	calendar year.
158	158	Sec. 1369.558. PROFESSIONAL STANDARDS AND SCOPE OF PRACTICE
159	159	REQUIREMENTS. (a) A health benefit plan issuer or pharmacy benefit
160	160	manager may not as a condition of a contract with a pharmacist or
161	161	pharmacy:
162	162	(1) except as provided by Subsection (b), require
163	163	pharmacist or pharmacy accreditation standards or recertification
164	164	requirements inconsistent with, more stringent than, or in addition
165	165	to federal and state requirements; or
166	166	(2) prohibit a licensed pharmacist or pharmacy from
167	167	dispensing any drug that may be dispensed under the pharmacist's or
168	168	pharmacy's license unless:
169	169	(A) applicable state or federal law prohibits the
170	170	pharmacist or pharmacy from dispensing the drug; or
171	171	(B) the manufacturer of the drug requires that a
172	172	pharmacist or pharmacy possess one or more accreditations or
173	173	certifications to dispense the drug and the pharmacist or pharmacy
174	174	does not meet the requirement.
175	175	(b) A health benefit plan issuer or pharmacy benefit manager
176	176	may require as a condition of a contract with a specialty pharmacy
177	177	that the specialty pharmacy obtain accreditation from not more than
178	178	two of the following independent accreditation organizations:
179	179	(1) URAC, formerly the Utilization Review
180	180	Accreditation Commission;
181	181	(2) The Joint Commission;
182	182	(3) Accreditation Commission for Health Care (ACHC);
183	183	(4) Center for Pharmacy Practice Accreditation
184	184	(CPPA); or
185	185	(5) National Committee for Quality Assurance (NCQA).
186	186	Sec. 1369.559. RETALIATION PROHIBITED. (a) A pharmacy
187	187	benefit manager may not retaliate against a pharmacist or pharmacy
188	188	based on the pharmacist's or pharmacy's exercise of any right or
189	189	remedy under this chapter. Retaliation prohibited by this section
190	190	includes:
191	191	(1) terminating or refusing to renew a contract with
192	192	the pharmacist or pharmacy;
193	193	(2) subjecting the pharmacist or pharmacy to increased
194	194	audits; or
195	195	(3) failing to promptly pay the pharmacist or pharmacy
196	196	any money owed by the pharmacy benefit manager to the pharmacist or
197	197	pharmacy.
198	198	(b) For purposes of this section, a pharmacy benefit manager
199	199	is not considered to have retaliated against a pharmacist or
200	200	pharmacy if the pharmacy benefit manager:
201	201	(1) takes an action in response to a credible
202	202	allegation of fraud against the pharmacist or pharmacy; and
203	203	(2) provides reasonable notice to the pharmacist or
204	204	pharmacy of the allegation of fraud and the basis of the allegation
205	205	before taking the action.
206	206	Sec. 1369.560. WAIVER PROHIBITED. The provisions of this
207	207	subchapter may not be waived, voided, or nullified by contract.
208	208	SECTION 2. The change in law made by this Act applies only
209	209	to a contract entered into or renewed on or after the effective date
210	210	of this Act. A contract entered into or renewed before the
211	211	effective date of this Act is governed by the law as it existed
212	212	immediately before the effective date of this Act, and that law is
213	213	continued in effect for that purpose.
214	214	SECTION 3. This Act takes effect September 1, 2021.