Texas 2025 - 89th Regular

Texas House Bill HB2978 Compare Versions

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

Old	New	Differences
1	1	89R6156 SCL-D
2	2	By: Harris H.B. No. 2978
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7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to the minimum reimbursement amount for prescription drugs
10	10	and devices to health benefit plan network pharmacists and
11	11	pharmacies.
12	12	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
13	13	SECTION 1. Chapter 1369, Insurance Code, is amended by
14	14	adding Subchapter H-1 to read as follows:
15	15	SUBCHAPTER H-1. MINIMUM REIMBURSEMENT AMOUNT FOR NETWORK
16	16	PHARMACISTS AND PHARMACIES
17	17	Sec. 1369.371. DEFINITIONS. In this subchapter:
18	18	(1) "Health benefit plan" has the meaning assigned by
19	19	Section 1369.251.
20	20	(2) "Pharmacy benefit manager" means:
21	21	(A) a pharmacy benefit manager, as defined by
22	22	Section 4151.151; or
23	23	(B) a health benefit plan issuer or sponsor that
24	24	administers pharmacy benefits in connection with the health benefit
25	25	plan.
26	26	Sec. 1369.372. APPLICABILITY OF SUBCHAPTER. This
27	27	subchapter applies to the administration of pharmacy benefits by or
28	28	on behalf of an issuer or sponsor of a health benefit plan.
29	29	Sec. 1369.373. EXCEPTIONS TO APPLICABILITY OF
30	30	SUBCHAPTER. This subchapter does not apply to an issuer or
31	31	provider of health benefits under or a pharmacy benefit manager
32	32	administering pharmacy benefits under:
33	33	(1) the state Medicaid program, including the Medicaid
34	34	managed care program operated under Chapter 540, Government Code;
35	35	(2) the child health plan program under Chapter 62,
36	36	Health and Safety Code;
37	37	(3) the TRICARE military health system;
38	38	(4) a basic coverage plan under Chapter 1551;
39	39	(5) a basic plan under Chapter 1575;
40	40	(6) a coverage plan under Chapter 1579;
41	41	(7) a plan providing basic coverage under Chapter
42	42	1601; or
43	43	(8) a workers' compensation insurance policy or other
44	44	form of providing medical benefits under Title 5, Labor Code.
45	45	Sec. 1369.374. REIMBURSEMENT MINIMUM; DISPENSING FEES.
46	46	(a) Notwithstanding any other law and subject to Subsection (c), a
47	47	pharmacy benefit manager may not reimburse a pharmacist or pharmacy
48	48	under contract with the pharmacy benefit manager for a prescription
49	49	drug or device an amount that is less than the actual cost to that
50	50	pharmacist or pharmacy for the drug or device.
51	51	(b) Subsection (a) does not apply to a pharmacy benefit
52	52	manager using an ingredient cost reimbursement methodology for a
53	53	prescription drug or device that is identical to the reimbursement
54	54	methodology for the ingredient cost of the drug or device under the
55	55	Medicaid fee-for-service model.
56	56	(c) In calculating the reimbursement amount for a
57	57	prescription drug or device under Subsection (a), a pharmacy
58	58	benefit manager may not include in that calculation the amount of a
59	59	professional dispensing fee payable to the pharmacist or pharmacy
60	60	that dispensed the drug or device.
61	61	(d) A pharmacy benefit manager shall reimburse a pharmacist
62	62	or pharmacy under contract with the pharmacy benefit manager a
63	63	professional dispensing fee for a prescription drug or device in an
64	64	amount that is not less than the amount of the dispensing fee paid
65	65	for the drug or device under the Medicaid fee-for-service model.
66	66	Sec. 1369.375. APPEAL: PROCEDURES REQUIRED. (a) A
67	67	pharmacy benefit manager shall provide in the contract with each
68	68	pharmacist or pharmacy a procedure for the pharmacist or pharmacy
69	69	to appeal a reimbursement of a prescription drug or device that the
70	70	pharmacist or pharmacy alleges to not be in compliance with Section
71	71	1369.374 on or before the seventh day after the date the
72	72	reimbursement is provided.
73	73	(b) The appeal procedure provision must:
74	74	(1) be approved by the commissioner; and
75	75	(2) permit a pharmacist or pharmacy or the
76	76	pharmacist's or pharmacy's designated agent to file an appeal using
77	77	the standard appeal form described by Subsection (d).
78	78	(c) A pharmacy benefit manager shall file an appeal
79	79	procedure provision with the department in the form and manner
80	80	prescribed by the commissioner.
81	81	(d) The commissioner shall develop and make available to
82	82	pharmacy benefit managers a standard appeal form to be used to file
83	83	an appeal of a reimbursement alleged to not be in compliance with
84	84	Section 1369.374.
85	85	Sec. 1369.376. APPEAL: PHARMACIST OR PHARMACY AGENT. A
86	86	pharmacist or pharmacy electing to appeal a reimbursement under a
87	87	procedure described by Section 1369.375 may designate a pharmacy
88	88	services administrative organization or another agent to file and
89	89	conduct the appeal.
90	90	Sec. 1369.377. APPEAL: EFFECT OF PHARMACIST OR PHARMACY
91	91	PREVAILING. (a) In this section, "similarly situated pharmacist
92	92	or pharmacy" means a pharmacist or pharmacy:
93	93	(1) that is under contract with the pharmacy benefit
94	94	manager;
95	95	(2) that purchases the prescription drug or device
96	96	that is the subject of an appeal of a reimbursement not in
97	97	compliance with Section 1369.374 from the same pharmaceutical
98	98	wholesaler as the pharmacist or pharmacy that prevailed in the
99	99	appeal; and
100	100	(3) to which the pharmacy benefit manager also applies
101	101	the challenged reimbursement rate or actual cost for the
102	102	prescription drug or device.
103	103	(b) If a pharmacist or pharmacy prevails in an appeal of a
104	104	reimbursement alleged to not be in compliance with Section
105	105	1369.374, the pharmacy benefit manager shall, not later than the
106	106	seventh day after the date the pharmacist or pharmacy prevailed:
107	107	(1) make the necessary change to the challenged
108	108	reimbursement or actual cost;
109	109	(2) if the product involved in the appeal is a
110	110	prescription drug, provide the pharmacist or pharmacy the national
111	111	drug code number for the drug;
112	112	(3) permit the pharmacist or pharmacy to reverse and
113	113	rebill the claim that is the subject of the appeal;
114	114	(4) pay or waive any transaction fee required to
115	115	reverse or rebill the claim;
116	116	(5) reimburse the pharmacist or pharmacy at least the
117	117	pharmacist's or pharmacy's actual cost for the prescription drug or
118	118	device; and
119	119	(6) apply the findings from the appeal to the
120	120	reimbursement rate and actual cost for the prescription drug or
121	121	device that is the subject of the appeal to other similarly situated
122	122	pharmacists and pharmacies.
123	123	Sec. 1369.378. APPEAL: EFFECT OF PHARMACY BENEFIT MANAGER
124	124	PREVAILING. (a) If a pharmacy benefit manager prevails in an
125	125	appeal of a reimbursement alleged to not be in compliance with
126	126	Section 1369.374 and the prescription drug or device that is the
127	127	subject of the appeal is available at a cost equal to or less than
128	128	the challenged reimbursement, the pharmacy benefit manager shall,
129	129	not later than the seventh day after the date the pharmacy benefit
130	130	manager prevails:
131	131	(1) provide the pharmacist or pharmacy with the name
132	132	of the national or regional pharmaceutical wholesaler operating in
133	133	this state that has the drug or device in stock at a price that is
134	134	equal to or less than the challenged reimbursement; and
135	135	(2) as applicable, provide the national drug code
136	136	number for the drug or the unique device identifier for the device.
137	137	(b) If a pharmacy benefit manager fails to comply with
138	138	Subsection (a), the pharmacy benefit manager shall:
139	139	(1) adjust the challenged reimbursement to an amount
140	140	equal to or greater than the pharmacist's or pharmacy's actual cost;
141	141	(2) permit the pharmacist or pharmacy to reverse and
142	142	rebill each claim affected by the inability to obtain the drug or
143	143	device at a cost equal to or less than the challenged reimbursement;
144	144	and
145	145	(3) pay or waive any transaction fee required to
146	146	reverse and rebill each affected claim.
147	147	SECTION 2. Subchapter H-1, Chapter 1369, Insurance Code, as
148	148	added by this Act, applies only to a health benefit plan delivered,
149	149	issued for delivery, or renewed on or after January 1, 2026.
150	150	SECTION 3. This Act takes effect September 1, 2025.