Texas 2021 - 87th Regular

Texas Senate Bill SB679 Compare Versions

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

Old	New	Differences
1	1	87R3428 JES-F
2	2	By: Kolkhorst S.B. No. 679
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to the regulation of pharmacy benefit managers and health
8	8	benefit plan issuers in relation to prescription drug coverage.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Chapter 1369, Insurance Code, is amended by
11	11	adding Subchaper A-1 to read as follows:
12	12	SUBCHAPTER A-1. COMPLAINTS
13	13	Sec. 1369.021. COMPLAINTS AGAINST PHARMACY BENEFIT
14	14	MANAGERS. (a) The commissioner may receive and review written
15	15	complaints alleging violations of this chapter by a pharmacy
16	16	benefit manager.
17	17	(b) Based on review under Subsection (a), if the
18	18	commissioner has reason to believe that a pharmacy benefit manager
19	19	engaged in a course of conduct exhibited through a pattern or
20	20	practice that violates this chapter or constitutes improper,
21	21	fraudulent, or dishonest contract performance with the pharmacist
22	22	or pharmacy, the commissioner may conduct any investigation
23	23	necessary to determine whether the pattern or practice exists.
24	24	(c) The commissioner shall take appropriate disciplinary
25	25	action as provided by this code against the pharmacy benefit
26	26	manager if the commissioner finds, based on an investigation
27	27	authorized by Subsection (b), that the pharmacy benefit manager
28	28	engaged in a course of conduct exhibited through a pattern or
29	29	practice that violates this chapter or constitutes improper,
30	30	fraudulent, or dishonest contract performance with the pharmacist
31	31	or pharmacy.
32	32	(d) The commissioner may exercise the subpoena authority
33	33	under Section 36.152 in an investigation under this section.
34	34	SECTION 2. Chapter 1369, Insurance Code, is amended by
35	35	adding Subchapter I to read as follows:
36	36	SUBCHAPTER I. RELATIONSHIP TO PHARMACISTS AND PHARMACIES
37	37	Sec. 1369.551. DEFINITIONS. In this subchapter:
38	38	(1) "Affiliated pharmacist of pharmacy" means a
39	39	pharmacist or pharmacy that directly, or indirectly through one or
40	40	more intermediaries, controls or is controlled by, or is under
41	41	common control with, a pharmacy benefit manager.
42	42	(2) "Pharmacy benefit manager" means a person, other
43	43	than a pharmacist or pharmacy, who acts as an administrator in
44	44	connection with pharmacy benefits.
45	45	Sec. 1369.552. APPLICABILITY OF SUBCHAPTER. (a) This
46	46	subchapter applies only to a health benefit plan that provides
47	47	benefits for medical or surgical expenses incurred as a result of a
48	48	health condition, accident, or sickness, including an individual,
49	49	group, blanket, or franchise insurance policy or insurance
50	50	agreement, a group hospital service contract, or an individual or
51	51	group evidence of coverage or similar coverage document that is
52	52	offered by:
53	53	(1) an insurance company;
54	54	(2) a group hospital service corporation operating
55	55	under Chapter 842;
56	56	(3) a health maintenance organization operating under
57	57	Chapter 843;
58	58	(4) an approved nonprofit health corporation that
59	59	holds a certificate of authority under Chapter 844;
60	60	(5) a multiple employer welfare arrangement that holds
61	61	a certificate of authority under Chapter 846;
62	62	(6) a stipulated premium company operating under
63	63	Chapter 884;
64	64	(7) a fraternal benefit society operating under
65	65	Chapter 885;
66	66	(8) a Lloyd's plan operating under Chapter 941; or
67	67	(9) an exchange operating under Chapter 942.
68	68	(b) Notwithstanding any other law, this subchapter applies
69	69	to:
70	70	(1) a small employer health benefit plan subject to
71	71	Chapter 1501, including coverage provided through a health group
72	72	cooperative under Subchapter B of that chapter;
73	73	(2) a standard health benefit plan issued under
74	74	Chapter 1507;
75	75	(3) health benefits provided by or through a church
76	76	benefits board under Subchapter I, Chapter 22, Business
77	77	Organizations Code;
78	78	(4) group health coverage made available by a school
79	79	district in accordance with Section 22.004, Education Code;
80	80	(5) a regional or local health care program operated
81	81	under Section 75.104, Health and Safety Code; and
82	82	(6) a self-funded health benefit plan sponsored by a
83	83	professional employer organization under Chapter 91, Labor Code.
84	84	(c) This subchapter does not apply to an issuer or provider
85	85	of health benefits under or a pharmacy benefit manager
86	86	administering pharmacy benefits under a workers' compensation
87	87	insurance policy or other form of providing medical benefits under
88	88	Title 5, Labor Code.
89	89	Sec. 1369.553. REDUCTION OF CERTAIN CLAIM PAYMENT AMOUNTS
90	90	PROHIBITED. (a) A health benefit plan issuer or pharmacy benefit
91	91	manager may not directly or indirectly reduce the amount of a claim
92	92	payment to a pharmacist or pharmacy after adjudication of the claim
93	93	through the use of an aggregated effective rate, a quality
94	94	assurance program, other direct or indirect remuneration fee, or
95	95	otherwise, except in accordance with an audit performed under
96	96	Subchapter F.
97	97	(b) Nothing in this section prohibits a health benefit plan
98	98	issuer or pharmacy benefit manager from increasing a claim payment
99	99	amount after adjudication of the claim.
100	100	(c) Notwithstanding any other law, this section applies to
101	101	the Medicaid managed care program operated under Chapter 533,
102	102	Government Code.
103	103	Sec. 1369.554. PROFESSIONAL STANDARDS AND SCOPE OF PRACTICE
104	104	REQUIREMENTS. A health benefit plan issuer or pharmacy benefit
105	105	manager may not as a condition of a contract with a pharmacist or
106	106	pharmacy:
107	107	(1) require pharmacist or pharmacy accreditation
108	108	standards or recertification requirements inconsistent with, more
109	109	stringent than, or in addition to federal and state requirements;
110	110	or
111	111	(2) prohibit a licensed pharmacist or pharmacy from
112	112	dispensing any drug, including a specialty drug, that may be
113	113	dispensed under the pharmacist's or pharmacy's license unless
114	114	applicable state or federal law prohibits the pharmacist or
115	115	pharmacy from dispensing the drug.
116	116	Sec. 1369.555. RESTRICTIONS ON MAIL ORDER PHARMACY
117	117	SERVICES. A pharmacy benefit manager may not require an enrollee to
118	118	use a mail order pharmacy.
119	119	Sec. 1369.556. DELIVERY OF DRUGS. Except in a case in which
120	120	the health benefit plan issuer or pharmacy benefit manager makes a
121	121	credible allegation of fraud against the pharmacist or pharmacy and
122	122	provides reasonable notice of the allegation and the basis of the
123	123	allegation to the pharmacist or pharmacy, a health benefit plan
124	124	issuer or pharmacy benefit manager may not as a condition of a
125	125	contract with a pharmacist or pharmacy prohibit the pharmacist or
126	126	pharmacy from:
127	127	(1) mailing or delivering a drug to a patient on the
128	128	patient's request, to the extent permitted by law; or
129	129	(2) charging a shipping and handling fee to a patient
130	130	requesting a prescription be mailed or delivered if the pharmacist
131	131	or pharmacy discloses to the patient before the delivery:
132	132	(A) the fee that will be charged; and
133	133	(B) that the fee may not be reimbursable by the
134	134	health benefit plan issuer or pharmacy benefit manager.
135	135	Sec. 1369.557. PROHIBITION ON CERTAIN REFERRALS. (a) A
136	136	health benefit plan issuer or pharmacy benefit manager may not
137	137	steer or direct a patient to use an affiliated pharmacist or
138	138	pharmacy through:
139	139	(1) any oral or written communication, including:
140	140	(A) online messaging regarding the pharmacist or
141	141	pharmacy; or
142	142	(B) patient- or prospective patient-specific
143	143	advertising, marketing, or promotion of the pharmacist or pharmacy;
144	144	or
145	145	(2) offering or implementing a health benefit plan
146	146	design that requires or induces a patient to use an affiliated
147	147	pharmacist or pharmacy, including by providing for reduced
148	148	cost-sharing amounts if the patient uses the pharmacist or
149	149	pharmacy.
150	150	(b) This section does not prohibit a health benefit plan
151	151	issuer or pharmacy benefit manager from including an affiliated
152	152	pharmacist or pharmacy in the issuer's or manager's patient
153	153	communications, including in a patient- or prospective
154	154	patient-specific communication, if the communication:
155	155	(1) is regarding in-network pharmacies and prices for
156	156	a health benefit plan;
157	157	(2) is accurate; and
158	158	(3) includes in-network pharmacists or pharmacies
159	159	that are not affiliated pharmacists or pharmacies.
160	160	(c) An affiliated pharmacist or pharmacy may not present a
161	161	claim for payment to any individual or entity, including to a
162	162	third-party payor, health benefit plan, or pharmacy benefit
163	163	manager, for a health care service or supply provided to a patient
164	164	who was improperly steered or directed to use the affiliated
165	165	pharmacist or pharmacy in violation of Subsection (a).
166	166	Sec. 1369.558. PROHIBITION ON SHARING PATIENT INFORMATION
167	167	FOR CERTAIN PURPOSES. (a) In this section, "commercial purpose"
168	168	does not include pharmacy reimbursement, formulary compliance,
169	169	pharmaceutical care, utilization review by a health care provider,
170	170	or a public health activity authorized by law.
171	171	(b) A health benefit plan issuer or pharmacy benefit manager
172	172	may not transfer to or receive from an affiliated pharmacist or
173	173	pharmacy a record containing patient- or prescriber-identifiable
174	174	prescription information for a commercial purpose.
175	175	SECTION 3. The change in law made by this Act applies only
176	176	to a contract entered into or renewed on or after the effective date
177	177	of this Act. A contract entered into or renewed before the
178	178	effective date of this Act is governed by the law as it existed
179	179	immediately before the effective date of this Act, and that law is
180	180	continued in effect for that purpose.
181	181	SECTION 4. This Act takes effect September 1, 2021.