Texas 2025 - 89th Regular

Texas House Bill HB3317 Compare Versions

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

Old	New	Differences
1	1	89R11480 SCF-D
2	2	By: Hefner H.B. No. 3317
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7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to the relationship between pharmacists or pharmacies and
10	10	health benefit plan issuers or pharmacy benefit managers.
11	11	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12	12	SECTION 1. Section 1369.153, Insurance Code, is amended by
13	13	adding Subsection (e) to read as follows:
14	14	(e) The commissioner by rule shall require a health benefit
15	15	plan that provides pharmacy benefits to enrollees to include on the
16	16	front of the identification card of each enrollee a unique
17	17	identifier that enables a pharmacist or pharmacy to determine when
18	18	submitting a claim that the enrollee's health benefit plan or
19	19	pharmacy benefit plan is subject to regulation by the department.
20	20	For purposes of this subsection, the commissioner may require a
21	21	unique bank identification number, processor control number, or
22	22	group number.
23	23	SECTION 2. Section 1369.252, Insurance Code, is amended to
24	24	read as follows:
25	25	Sec. 1369.252. EXCEPTIONS TO APPLICABILITY OF SUBCHAPTER.
26	26	This subchapter does not apply to an issuer or provider of health
27	27	benefits under or a pharmacy benefit manager administering pharmacy
28	28	benefits under:
29	29	(1) the state Medicaid program;
30	30	(2) the federal Medicare program;
31	31	(3) the state child health plan or health benefits
32	32	plan for children under Chapter 62 or 63, Health and Safety Code;
33	33	(4) the TRICARE military health system; or
34	34	(5) a workers' compensation insurance policy or other
35	35	form of providing medical benefits under Title 5, Labor Code[; or
36	36	[(6) a self-funded health benefit plan as defined by
37	37	the Employee Retirement Income Security Act of 1974 (29 U.S.C.
38	38	Section 1001 et seq.)].
39	39	SECTION 3. The heading to Section 1369.259, Insurance Code,
40	40	is amended to read as follows:
41	41	Sec. 1369.259. LIMITATIONS ON PAYMENT ADJUSTMENTS AND
42	42	[CALCULATION OF] RECOUPMENT; USE OF EXTRAPOLATION PROHIBITED.
43	43	SECTION 4. Section 1369.259, Insurance Code, is amended by
44	44	adding Subsections (a-1) and (e) to read as follows:
45	45	(a-1) A health benefit plan issuer or pharmacy benefit
46	46	manager may not, as the result of an audit, deny or reduce a claim
47	47	payment made to a pharmacist or pharmacy after adjudication of the
48	48	claim unless:
49	49	(1) the original claim was submitted fraudulently;
50	50	(2) the original claim payment was incorrect because
51	51	the pharmacist or pharmacy had already been paid for the pharmacist
52	52	service; or
53	53	(3) the pharmacist or pharmacy made a substantive
54	54	non-clerical or non-recordkeeping error that led to the patient
55	55	receiving the wrong prescription drug or dosage.
56	56	(e) Except for a claim described by Subsection (a-1), a
57	57	health benefit plan issuer or pharmacy benefit manager:
58	58	(1) may only recoup the dispensing fee paid by the
59	59	health benefit plan issuer or pharmacy benefit manager to the
60	60	pharmacist or pharmacy associated with the audited claim; and
61	61	(2) may not recoup from the pharmacist or pharmacy the
62	62	cost of the drug or any other amount related to the claim.
63	63	SECTION 5. Subchapter M, Chapter 1369, Insurance Code, is
64	64	amended by adding Sections 1369.6021, 1369.6022, 1369.6023,
65	65	1369.6024, and 1369.6025 to read as follows:
66	66	Sec. 1369.6021. ONLINE ACCESS TO PHARMACY BENEFIT NETWORK
67	67	CONTRACT. A health benefit plan issuer or pharmacy benefit manager
68	68	shall make available to any pharmacist or pharmacy in the issuer's
69	69	or manager's pharmacy benefit network access to a secure, online
70	70	portal through which the pharmacist or pharmacy may access all
71	71	pharmacy benefit network contracts between the health benefit plan
72	72	issuer or pharmacy benefit manager and the pharmacist or pharmacy,
73	73	including any contract addendums.
74	74	Sec. 1369.6022. PHARMACY BENEFIT NETWORK CONTRACT
75	75	MODIFICATIONS AND ADDENDUMS. (a) A pharmacist or pharmacy must
76	76	have an opportunity to refuse a proposed modification or addendum
77	77	to a pharmacy benefit network contract. A proposed modification or
78	78	addendum may not take effect without the signed approval of the
79	79	pharmacist or pharmacy.
80	80	(b) A health benefit plan issuer or pharmacy benefit manager
81	81	must, not later than the 90th day before the date a proposed
82	82	modification or addendum to a pharmacy benefit network contract is
83	83	to take effect:
84	84	(1) post the proposed modification or addendum to the
85	85	online portal described by Section 1369.6021; and
86	86	(2) provide to the pharmacist or pharmacy notice of
87	87	the proposed modification or addendum by e-mail, including:
88	88	(A) a link to the online portal;
89	89	(B) the National Council for Prescription Drug
90	90	Programs number or other identifier approved by the commissioner
91	91	for the pharmacist or pharmacy to which the proposed modification
92	92	or addendum applies; and
93	93	(C) a description of the proposed modification or
94	94	addendum in a manner that allows the pharmacist or pharmacy to
95	95	compare the proposed modification or addendum to the current
96	96	contract.
97	97	(c) A pharmacy benefit network contract may not incorporate
98	98	by reference a document not included in a contract or contract
99	99	attachment, including a provider manual. All financial terms,
100	100	including reimbursement rates and methodology, must be set forth in
101	101	the contract.
102	102	Sec. 1369.6023. PHARMACY BENEFIT NETWORK CONTRACT
103	103	DISCLOSURE. A pharmacy benefit network contract must state that
104	104	the contract is subject to this chapter and any rules adopted by the
105	105	commissioner under this chapter.
106	106	Sec. 1369.6024. PHARMACY BENEFIT NETWORK CONTRACT FEE
107	107	LIMITATIONS. (a) A health benefit plan issuer or pharmacy benefit
108	108	manager may not charge a fee, including an application or
109	109	participation fee, before providing a pharmacist or pharmacy with
110	110	the full proposed pharmacy benefit network contract, including any
111	111	financial terms applicable to the contract and corresponding
112	112	pharmacy benefit network.
113	113	(b) A health benefit plan issuer or pharmacy benefit manager
114	114	may not charge a pharmacist or pharmacy already participating in
115	115	the pharmacy benefit network a fee related to re-credentialing or
116	116	re-enrollment or a similar fee.
117	117	Sec. 1369.6025. PHARMACY BENEFIT NETWORK PARTICIPATION
118	118	REQUIREMENTS PROHIBITED. A health benefit plan issuer or pharmacy
119	119	benefit manager may not:
120	120	(1) require a pharmacist or pharmacy to participate in
121	121	a pharmacy benefit network;
122	122	(2) condition a pharmacist's or pharmacy's
123	123	participation in a pharmacy benefit network on participation in any
124	124	other pharmacy benefit network; or
125	125	(3) penalize a pharmacist or pharmacy for refusing to
126	126	participate in a pharmacy benefit network.
127	127	SECTION 6. Section 1369.605, Insurance Code, is amended to
128	128	read as follows:
129	129	Sec. 1369.605. NETWORK CONTRACT FEE SCHEDULE. A pharmacy
130	130	benefit network contract must include [specify or reference] a
131	131	[separate] fee schedule. [Unless otherwise available in the
132	132	contract, the fee schedule must be provided electronically in an
133	133	easily accessible and complete spreadsheet format and, on request,
134	134	in writing to each contracted pharmacist and pharmacy.] The fee
135	135	schedule must describe:
136	136	(1) specific services or procedures that the
137	137	pharmacist or pharmacy may deliver and the amount of the
138	138	corresponding payment;
139	139	(2) a methodology for calculating the amount of the
140	140	payment based on a published fee schedule; or
141	141	(3) any other reasonable manner that provides an
142	142	ascertainable amount for payment for services.
143	143	SECTION 7. Section 1369.259(d), Insurance Code, is
144	144	repealed.
145	145	SECTION 8. (a) Section 1369.153, Insurance Code, as
146	146	amended by this Act, applies only to a health benefit plan
147	147	delivered, issued for delivery, or renewed on or after January 1,
148	148	2026. A health benefit plan delivered, issued for delivery, or
149	149	renewed before January 1, 2026, is governed by the law as it existed
150	150	immediately before the effective date of this Act, and that law is
151	151	continued in effect for that purpose.
152	152	(b) Chapter 1369, Insurance Code, as amended by this Act,
153	153	applies only to a contract entered into or renewed on or after the
154	154	effective date of this Act. A contract entered into or renewed
155	155	before the effective date of this Act is governed by the law as it
156	156	existed immediately before the effective date of this Act, and that
157	157	law is continued in effect for that purpose.
158	158	SECTION 9. This Act takes effect September 1, 2025.