89R4791 JG-F
By: Oliverson H.B. No. 4533
A BILL TO BE ENTITLED
AN ACT
relating to the reimbursement of prescription drugs under Medicaid
and the child health plan program.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter F, Chapter 540, Government Code, as
effective April 1, 2025, is amended by adding Section 540.02731 to
read as follows:
Sec. 540.02731. PHARMACY BENEFIT PLAN: REIMBURSEMENT
METHODOLOGY FOR PRESCRIPTION DRUGS; STUDY. (a) Notwithstanding
any other law and in accordance with rules the executive
commissioner adopts, a Medicaid managed care organization or a
pharmacy benefit manager administering a pharmacy benefit program
on behalf of the organization shall reimburse a pharmacy or
pharmacist, including a Texas retail pharmacy or a Texas specialty
pharmacy, that dispenses a prescribed prescription drug to a
recipient an amount that is not less than the lesser of:
(1) the reimbursement amount for the drug under the
vendor drug program, including a dispensing fee that is not less
than the dispensing fee for the drug under the vendor drug program;
or
(2) the amount claimed by the pharmacy or pharmacist,
including the gross amount due or the usual and customary charge to
the public for the drug.
(b) The methodology the executive commissioner adopts by
rule to determine Texas pharmacies' actual acquisition cost (AAC)
for purposes of the vendor drug program must be consistent with the
actual prices Texas retail pharmacies, Texas specialty pharmacies,
and Texas long-term care pharmacies, as applicable, pay to acquire
prescription drugs.
(c) The executive commissioner shall develop a process for
determining Texas pharmacies' actual acquisition cost (AAC) for
prescription drugs that:
(1) to the extent possible, bases the cost on cost data
obtained from surveys of Texas pharmacies, including retail,
specialty, and long-term care pharmacies, conducted by the
commission on at least a monthly basis; and
(2) uses an alternative method for determining the
cost with respect to prescription drugs for which insufficient cost
data is available from surveys conducted under Subdivision (1).
(d) The executive commissioner may require Texas pharmacies
to respond or submit information in response to surveys described
by Subsection (c)(1) as a condition of participation as a Medicaid
provider.
(e) The dispensing fees the executive commissioner adopts
under Subsection (a) must be based on, as appropriate:
(1) Texas retail pharmacies' professional dispensing
costs for retail prescription drugs; or
(2) Texas specialty pharmacies' professional
dispensing costs for specialty prescription drugs.
(f) At least once every two years, the commission shall
conduct a study of Texas pharmacies' dispensing costs for retail
prescription drugs and specialty prescription drugs. Based on the
results of the study, the executive commissioner shall adjust the
minimum amount of the retail pharmacy professional dispensing fee
and specialty pharmacy professional dispensing fee under
Subsection (a).
(g) A contract to which this subchapter applies must require
the contracting Medicaid managed care organization and any
subcontracted pharmacy benefit manager to comply with Subsection
(a).
SECTION 2. Subchapter D, Chapter 62, Health and Safety
Code, is amended by adding Section 62.160 to read as follows:
Sec. 62.160. PHARMACY BENEFIT PLAN: REIMBURSEMENT
METHODOLOGY FOR PRESCRIPTION DRUGS. A managed care organization
providing pharmacy benefits under the child health plan program or
a pharmacy benefit manager administering a pharmacy benefit program
on behalf of the organization shall comply with Section 540.02731,
Government Code.
SECTION 3. If before implementing any provision of this Act
a state agency determines that a waiver or authorization from a
federal agency is necessary for implementation of that provision,
the agency affected by the provision shall request the waiver or
authorization and may delay implementing that provision until the
waiver or authorization is granted.
SECTION 4. This Act takes effect March 1, 2026.