89R23465 SCF-D
By: Hefner H.B. No. 3317
Substitute the following for H.B. No. 3317:
By: Dean C.S.H.B. No. 3317
A BILL TO BE ENTITLED
AN ACT
relating to the relationship between pharmacists or pharmacies and
health benefit plan issuers or pharmacy benefit managers.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 1369.153, Insurance Code, is amended by
adding Subsection (e) to read as follows:
(e) A group number on an identification card provided to an
enrollee in a health benefit plan to which this subchapter applies
may be assigned only to enrollees in a health benefit plan to which
this subchapter applies.
SECTION 2. The heading to Section 1369.259, Insurance Code,
is amended to read as follows:
Sec. 1369.259. LIMITATIONS ON PAYMENT ADJUSTMENTS AND
[CALCULATION OF] RECOUPMENT; USE OF EXTRAPOLATION PROHIBITED.
SECTION 3. Section 1369.259, Insurance Code, is amended by
adding Subsections (a-1), (e), and (f) to read as follows:
(a-1) Subject to Subsections (e) and (f), a health benefit
plan issuer or pharmacy benefit manager may not, as the result of an
audit, deny or reduce a claim payment made to a pharmacist or
pharmacy after adjudication of the claim.
(e) A health benefit plan issuer or pharmacy benefit manager
may recoup from a pharmacist or pharmacy the cost of a prescription
drug and the dispensing fee for the drug if:
(1) the original claim was submitted fraudulently;
(2) the original claim payment was incorrect because
the pharmacist or pharmacy had already been paid for the pharmacist
service; or
(3) the pharmacist or pharmacy made a substantive
nonclerical or non-recordkeeping error that led to the patient
receiving the wrong prescription drug or dosage.
(f) A health benefit plan issuer or pharmacy benefit manager
may recoup only the dispensing fee from a pharmacist or pharmacy if
the pharmacist or pharmacy made a clerical error that led to an
overpayment.
SECTION 4. Subchapter M, Chapter 1369, Insurance Code, is
amended by adding Sections 1369.6021, 1369.6022, 1369.6023,
1369.6024, 1369.6025, 1369.6026, and 1369.6027 to read as follows:
Sec. 1369.6021. ONLINE ACCESS TO PHARMACY BENEFIT NETWORK
CONTRACT. A health benefit plan issuer or pharmacy benefit manager
shall make available to any pharmacist or pharmacy in the issuer's
or manager's pharmacy benefit network access to a secure, online
portal through which the pharmacist or pharmacy may access all
pharmacy benefit network contracts between the health benefit plan
issuer or pharmacy benefit manager and the pharmacist or pharmacy,
including any contract addendums.
Sec. 1369.6022. PHARMACY BENEFIT NETWORK CONTRACT: ADVERSE
MATERIAL CHANGES. (a) In this section, "adverse material change"
means a modification or addendum to a pharmacy benefit network
contract that would decrease a pharmacist's or pharmacy's payment
or compensation, change the pharmacist's or pharmacy's tier to a
less preferred tier, or change the administrative procedures in a
way that may reasonably be expected to increase the pharmacist's or
pharmacy's administrative expenses or decrease the pharmacist's or
pharmacy's payment or compensation. The term does not include:
(1) a decrease in payment or compensation resulting
solely from a change in a published governmental fee schedule on
which the payment or compensation is based if the applicability of
the schedule is clearly identified in the contract;
(2) a decrease in payment or compensation that was
anticipated under the terms of the contract, if the amount and date
of applicability of the decrease is clearly identified in the
contract;
(3) an administrative change that may increase the
pharmacist's or pharmacy's administrative expenses, the specific
applicability of which is clearly identified in the contract;
(4) a change that is required by federal or state law;
(5) a termination for cause; or
(6) a termination without cause at the end of the term
of the contract.
(b) A health benefit plan issuer or pharmacy benefit manager
may make an adverse material change to a pharmacy benefit network
contract during the term of the contract only with the mutual
agreement of the parties. A provision in the contract that allows a
health benefit plan issuer or pharmacy benefit manager to
unilaterally make an adverse material change during the term of the
contract is void and unenforceable.
(c) An adverse material change to a pharmacy benefit network
contract may not go into effect until the 120th day after the date
the pharmacist or pharmacy affirmatively agrees to the adverse
material change in writing.
(d) An adverse material change to a pharmacy benefit network
contract proposed by a health benefit plan issuer or pharmacy
benefit manager must include notice that clearly and conspicuously
states that a pharmacist or pharmacy may choose to not agree to the
adverse material change and that the decision to not agree to the
adverse material change does not affect:
(1) the terms of the pharmacist's or pharmacy's
existing contract with the health benefit plan issuer or pharmacy
benefit manager; or
(2) the pharmacist's or pharmacy's participation in
another pharmacy benefit network.
(e) A pharmacist's or pharmacy's decision to not agree to an
adverse material change to a pharmacy benefit network contract does
not affect:
(1) the terms of the pharmacist's or pharmacy's
existing contract; or
(2) the pharmacist's or pharmacy's participation in
another pharmacy benefit network.
(f) A health benefit plan issuer's or pharmacy benefit
manager's failure to include the notice described by Subsection (d)
with the proposed adverse material change makes an otherwise
agreed-to adverse material change void and unenforceable.
(g) This section does not apply to:
(1) a pharmacy benefit network contract:
(A) with an unspecified and indefinite duration;
(B) with no stated or automatic renewal period or
event; and
(C) that may only be terminated by notice from
one party to the other; or
(2) a proposed modification or addendum to a pharmacy
benefit network contract that is required by state or federal law or
rule.
Sec. 1369.6023. PHARMACY BENEFIT NETWORK CONTRACT: OTHER
MODIFICATIONS AND ADDENDUMS. (a) A health benefit plan issuer or
pharmacy benefit manager must, not later than the 90th day before
the date a proposed modification or addendum to a pharmacy benefit
network contract, other than an adverse material change as defined
by Section 1369.6022, is to take effect:
(1) post the proposed modification or addendum to the
online portal described by Section 1369.6021; and
(2) provide to the pharmacist or pharmacy notice of
the proposed modification or addendum by e-mail, including:
(A) a link to the online portal;
(B) the National Council for Prescription Drug
Programs number or other identifier approved by the commissioner
for the pharmacist or pharmacy to which the proposed modification
or addendum applies; and
(C) a description of the proposed modification or
addendum in a manner that allows the pharmacist or pharmacy to
compare the proposed modification or addendum to the current
contract.
(b) If a pharmacist or pharmacy does not respond before the
31st day after the date the pharmacist or pharmacy receives notice
of a proposed modification or addendum under Subsection (a), the
health benefit plan issuer or pharmacy benefit manager may consider
the proposed modification or addendum approved by the pharmacist or
pharmacy and the modification or addendum takes effect on the date
described by Subsection (a).
(c) A pharmacy benefit network contract may not incorporate
by reference a document not included in a contract or contract
attachment, including a provider manual described by Section
1369.6025. All financial terms, including reimbursement rates and
methodology, must be set forth in the contract.
(d) This section does not apply to:
(1) a pharmacy benefit network contract:
(A) with an unspecified and indefinite duration;
(B) with no stated or automatic renewal period or
event; and
(C) that may only be terminated by notice from
one party to the other; or
(2) a proposed modification or addendum to a pharmacy
benefit network contract that is required by state or federal law or
rule.
Sec. 1369.6024. PHARMACY BENEFIT NETWORK CONTRACT
DISCLOSURE. A pharmacy benefit network contract must state that
the contract is subject to this chapter and any rules adopted by the
commissioner under this chapter.
Sec. 1369.6025. PROVIDER MANUAL DISCLOSURE. A health
benefit plan issuer or pharmacy benefit manager shall:
(1) make a provider manual readily available on the
online portal described by Section 1369.6021; and
(2) post a modification or addendum to the provider
manual to the online portal in the same manner as a contract
modification or addendum under Section 1369.6023(a).
Sec. 1369.6026. PHARMACY BENEFIT NETWORK CONTRACT FEE
LIMITATIONS. A health benefit plan issuer or pharmacy benefit
manager may not charge a fee, including an application or
participation fee, before providing a pharmacist or pharmacy with
the full proposed pharmacy benefit network contract, including any
financial terms applicable to the contract and corresponding
pharmacy benefit network.
Sec. 1369.6027. PHARMACY BENEFIT NETWORK PARTICIPATION
REQUIREMENTS PROHIBITED. A health benefit plan issuer or pharmacy
benefit manager may not:
(1) require a pharmacist or pharmacy to participate in
a pharmacy benefit network;
(2) condition a pharmacist's or pharmacy's
participation in a pharmacy benefit network on participation in any
other pharmacy benefit network; or
(3) penalize a pharmacist or pharmacy for refusing to
participate in a pharmacy benefit network.
SECTION 5. Section 1369.605, Insurance Code, is amended to
read as follows:
Sec. 1369.605. NETWORK CONTRACT FEE SCHEDULE. A pharmacy
benefit network contract must include [specify or reference] a
[separate] fee schedule. [Unless otherwise available in the
contract, the fee schedule must be provided electronically in an
easily accessible and complete spreadsheet format and, on request,
in writing to each contracted pharmacist and pharmacy.] The fee
schedule must describe:
(1) specific services or procedures that the
pharmacist or pharmacy may deliver and the amount of the
corresponding payment;
(2) a methodology for calculating the amount of the
payment based on a published fee schedule; or
(3) any other reasonable manner that provides an
ascertainable amount for payment for services.
SECTION 6. Section 1369.259(d), Insurance Code, is
repealed.
SECTION 7. (a) Section 1369.153, Insurance Code, as
amended by this Act, applies only to a health benefit plan
delivered, issued for delivery, or renewed on or after January 1,
2026. A health benefit plan delivered, issued for delivery, or
renewed before January 1, 2026, 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.
(b) Chapter 1369, Insurance Code, as amended 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 8. This Act takes effect September 1, 2025.