Texas 2025 - 89th Regular

Texas Senate Bill SB1236 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1	1		By: Hughes, Blanco S.B. No. 1236
2		-	Sparks
	2	+	(In the Senate - Filed February 12, 2025;
	3	+	February 28, 2025, read first time and referred to Committee on
	4	+	Health & Human Services; April 14, 2025, reported adversely, with
	5	+	favorable Committee Substitute by the following vote: Yeas 9, Nays
	6	+	0; April 14, 2025, sent to printer.)
	7	+	Click here to see the committee vote
	8	+	COMMITTEE SUBSTITUTE FOR S.B. No. 1236 By: Perry
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7	13		A BILL TO BE ENTITLED
8	14		AN ACT
9	15		relating to the relationship between pharmacists or pharmacies and
10	16		health benefit plan issuers or pharmacy benefit managers.
11	17		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12	18		SECTION 1. Section 1369.153, Insurance Code, is amended by
13	19		adding Subsection (e) to read as follows:
14	20		(e) A group number on an identification card provided to an
15	21		enrollee in a health benefit plan to which this subchapter applies
16	22		may be assigned only to enrollees in a health benefit plan to which
17	23		this subchapter applies.
18	24		SECTION 2. The heading to Section 1369.259, Insurance Code,
19	25		is amended to read as follows:
20	26		Sec. 1369.259. LIMITATIONS ON PAYMENT ADJUSTMENTS AND
21	27		[CALCULATION OF] RECOUPMENT; USE OF EXTRAPOLATION PROHIBITED.
22	28		SECTION 3. Section 1369.259, Insurance Code, is amended by
23	29		adding Subsections (a-1), (e), and (f) to read as follows:
24	30		(a-1) Subject to Subsections (e) and (f), a health benefit
25	31		plan issuer or pharmacy benefit manager may not, as the result of an
26	32		audit, deny or reduce a claim payment made to a pharmacist or
27	33		pharmacy after adjudication of the claim.
28	34		(e) A health benefit plan issuer or pharmacy benefit manager
29	35		may recoup from a pharmacist or pharmacy the cost of a prescription
30	36		drug and the dispensing fee for the drug if:
31	37		(1) the original claim was submitted fraudulently;
32	38		(2) the original claim payment was incorrect because
33	39		the pharmacist or pharmacy had already been paid for the pharmacist
34	40		service; or
35	41		(3) the pharmacist or pharmacy made a substantive
36	42		nonclerical or non-recordkeeping error that led to the patient
37	43		receiving the wrong prescription drug or dosage.
38	44		(f) A health benefit plan issuer or pharmacy benefit manager
39	45		may recoup only the dispensing fee from a pharmacist or pharmacy if
40	46		the pharmacist or pharmacy made a clerical error that led to an
41	47		overpayment.
42	48		SECTION 4. Subchapter M, Chapter 1369, Insurance Code, is
43	49		amended by adding Sections 1369.6021, 1369.6022, 1369.6023,
44	50		1369.6024, 1369.6025, 1369.6026, and 1369.6027 to read as follows:
45	51		Sec. 1369.6021. ONLINE ACCESS TO PHARMACY BENEFIT NETWORK
46	52		CONTRACT. A health benefit plan issuer or pharmacy benefit manager
47	53		shall make available to any pharmacist or pharmacy in the issuer's
48	54		or manager's pharmacy benefit network access to a secure, online
49	55		portal through which the pharmacist or pharmacy may access all
50	56		pharmacy benefit network contracts between the health benefit plan
51	57		issuer or pharmacy benefit manager and the pharmacist or pharmacy,
52	58		including any contract addendums.
53	59		Sec. 1369.6022. PHARMACY BENEFIT NETWORK CONTRACT: ADVERSE
54	60		MATERIAL CHANGES. (a) In this section, "adverse material change"
55	61		means a modification or addendum to a pharmacy benefit network
56	62		contract that would decrease a pharmacist's or pharmacy's payment
57	63		or compensation, change the pharmacist's or pharmacy's tier to a
58	64		less preferred tier, or change the administrative procedures in a
59	65		way that may reasonably be expected to increase the pharmacist's or
60	66		pharmacy's administrative expenses or decrease the pharmacist's or
61	67		pharmacy's payment or compensation. The term does not include:
62	68		(1) a decrease in payment or compensation resulting
63	69		solely from a change in a published governmental fee schedule on
64	70		which the payment or compensation is based if the applicability of
65	71		the schedule is clearly identified in the contract;
66	72		(2) a decrease in payment or compensation that was
67	73		anticipated under the terms of the contract, if the amount and date
68	74		of applicability of the decrease is clearly identified in the
69	75		contract;
70	76		(3) an administrative change that may increase the
71	77		pharmacist's or pharmacy's administrative expenses, the specific
72	78		applicability of which is clearly identified in the contract;
73	79		(4) a change that is required by federal or state law;
74	80		(5) a termination for cause; or
75	81		(6) a termination without cause at the end of the term
76	82		of the contract.
77	83		(b) A health benefit plan issuer or pharmacy benefit manager
78	84		may make an adverse material change to a pharmacy benefit network
79	85		contract during the term of the contract only with the mutual
80	86		agreement of the parties. A provision in the contract that allows a
81	87		health benefit plan issuer or pharmacy benefit manager to
82	88		unilaterally make an adverse material change during the term of the
83	89		contract is void and unenforceable.
84	90		(c) An adverse material change to a pharmacy benefit network
85	91		contract may not go into effect until the 120th day after the date
86	92		the pharmacist or pharmacy affirmatively agrees to the adverse
87	93		material change in writing.
88	94		(d) An adverse material change to a pharmacy benefit network
89	95		contract proposed by a health benefit plan issuer or pharmacy
90	96		benefit manager must include notice that clearly and conspicuously
91	97		states that a pharmacist or pharmacy may choose to not agree to the
92	98		adverse material change and that the decision to not agree to the
93	99		adverse material change does not affect:
94	100		(1) the terms of the pharmacist's or pharmacy's
95	101		existing contract with the health benefit plan issuer or pharmacy
96	102		benefit manager; or
97	103		(2) the pharmacist's or pharmacy's participation in
98	104		another pharmacy benefit network.
99	105		(e) A pharmacist's or pharmacy's decision to not agree to an
100	106		adverse material change to a pharmacy benefit network contract does
101	107		not affect:
102	108		(1) the terms of the pharmacist's or pharmacy's
103	109		existing contract; or
104	110		(2) the pharmacist's or pharmacy's participation in
105	111		another pharmacy benefit network.
106	112		(f) A health benefit plan issuer's or pharmacy benefit
107	113		manager's failure to include the notice described by Subsection (d)
108	114		with the proposed adverse material change makes an otherwise
109	115		agreed-to adverse material change void and unenforceable.
110	116		(g) This section does not apply to:
111	117		(1) a pharmacy benefit network contract:
112	118		(A) with an unspecified and indefinite duration;
113	119		(B) with no stated or automatic renewal period or
114	120		event; and
115	121		(C) that may only be terminated by notice from
116	122		one party to the other; or
117	123		(2) a proposed modification or addendum to a pharmacy
118	124		benefit network contract that is required by state or federal law or
119	125		rule.
120	126		Sec. 1369.6023. PHARMACY BENEFIT NETWORK CONTRACT: OTHER
121	127		MODIFICATIONS AND ADDENDUMS. (a) A health benefit plan issuer or
122	128		pharmacy benefit manager must, not later than the 90th day before
123	129		the date a proposed modification or addendum to a pharmacy benefit
124	130		network contract, other than an adverse material change as defined
125	131		by Section 1369.6022, is to take effect:
126	132		(1) post the proposed modification or addendum to the
127	133		online portal described by Section 1369.6021; and
128	134		(2) provide to the pharmacist or pharmacy notice of
129	135		the proposed modification or addendum by e-mail, including:
130	136		(A) a link to the online portal;
131	137		(B) the National Council for Prescription Drug
132	138		Programs number or other identifier approved by the commissioner
133	139		for the pharmacist or pharmacy to which the proposed modification
134	140		or addendum applies; and
135	141		(C) a description of the proposed modification or
136	142		addendum in a manner that allows the pharmacist or pharmacy to
137	143		compare the proposed modification or addendum to the current
138	144		contract.
139	145		(b) If a pharmacist or pharmacy does not respond before the
140	146		31st day after the date the pharmacist or pharmacy receives notice
141	147		of a proposed modification or addendum under Subsection (a), the
142	148		health benefit plan issuer or pharmacy benefit manager may consider
143	149		the proposed modification or addendum approved by the pharmacist or
144	150		pharmacy and the modification or addendum takes effect on the date
145	151		described by Subsection (a).
146	152		(c) A pharmacy benefit network contract may not incorporate
147	153		by reference a document not included in a contract or contract
148	154		attachment, including a provider manual described by Section
149	155		1369.6025. All financial terms, including reimbursement rates and
150	156		methodology, must be set forth in the contract.
151	157		(d) This section does not apply to:
152	158		(1) a pharmacy benefit network contract:
153	159		(A) with an unspecified and indefinite duration;
154	160		(B) with no stated or automatic renewal period or
155	161		event; and
156	162		(C) that may only be terminated by notice from
157	163		one party to the other; or
158	164		(2) a proposed modification or addendum to a pharmacy
159	165		benefit network contract that is required by state or federal law or
160	166		rule.
161	167		Sec. 1369.6024. PHARMACY BENEFIT NETWORK CONTRACT
162	168		DISCLOSURE. A pharmacy benefit network contract must state that
163	169		the contract is subject to this chapter and any rules adopted by the
164	170		commissioner under this chapter.
165	171		Sec. 1369.6025. PROVIDER MANUAL DISCLOSURE. A health
166	172		benefit plan issuer or pharmacy benefit manager shall:
167	173		(1) make a provider manual readily available on the
168	174		online portal described by Section 1369.6021; and
169	175		(2) post a modification or addendum to the provider
170	176		manual to the online portal in the same manner as a contract
171	177		modification or addendum under Section 1369.6023(a).
172	178		Sec. 1369.6026. PHARMACY BENEFIT NETWORK CONTRACT FEE
173	179		LIMITATIONS. A health benefit plan issuer or pharmacy benefit
174	180		manager may not charge a fee, including an application or
175	181		participation fee, before providing a pharmacist or pharmacy with
176	182		the full proposed pharmacy benefit network contract, including any
177	183		financial terms applicable to the contract and corresponding
178	184		pharmacy benefit network.
179	185		Sec. 1369.6027. PHARMACY BENEFIT NETWORK PARTICIPATION
180	186		REQUIREMENTS PROHIBITED. A health benefit plan issuer or pharmacy
181	187		benefit manager may not:
182	188		(1) require a pharmacist or pharmacy to participate in
183	189		a pharmacy benefit network;
184	190		(2) condition a pharmacist's or pharmacy's
185	191		participation in a pharmacy benefit network on participation in any
186	192		other pharmacy benefit network; or
187	193		(3) penalize a pharmacist or pharmacy for refusing to
188	194		participate in a pharmacy benefit network.
189	195		SECTION 5. Section 1369.605, Insurance Code, is amended to
190	196		read as follows:
191	197		Sec. 1369.605. NETWORK CONTRACT FEE SCHEDULE. A pharmacy
192	198		benefit network contract must include [specify or reference] a
193	199		[separate] fee schedule. [Unless otherwise available in the
194	200		contract, the fee schedule must be provided electronically in an
195	201		easily accessible and complete spreadsheet format and, on request,
196	202		in writing to each contracted pharmacist and pharmacy.] The fee
197	203		schedule must describe:
198	204		(1) specific services or procedures that the
199	205		pharmacist or pharmacy may deliver and the amount of the
200	206		corresponding payment;
201	207		(2) a methodology for calculating the amount of the
202	208		payment based on a published fee schedule; or
203	209		(3) any other reasonable manner that provides an
204	210		ascertainable amount for payment for services.
205	211		SECTION 6. Section 1369.259(d), Insurance Code, is
206	212		repealed.
207	213		SECTION 7. (a) Section 1369.153, Insurance Code, as
208	214		amended by this Act, applies only to a health benefit plan
209	215		delivered, issued for delivery, or renewed on or after January 1,
210	216		2026. A health benefit plan delivered, issued for delivery, or
211	217		renewed before January 1, 2026, is governed by the law as it existed
212	218		immediately before the effective date of this Act, and that law is
213	219		continued in effect for that purpose.
214	220		(b) Chapter 1369, Insurance Code, as amended by this Act,
215	221		applies only to a contract entered into or renewed on or after the
216	222		effective date of this Act. A contract entered into or renewed
217	223		before the effective date of this Act is governed by the law as it
218	224		existed immediately before the effective date of this Act, and that
219	225		law is continued in effect for that purpose.
220	226		SECTION 8. This Act takes effect September 1, 2025.
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