Bill Text: TX HB1093 | 2021-2022 | 87th Legislature | Introduced
Bill Title: Relating to the regulation of pharmacy benefit managers and health benefit plan issuers in relation to prescription drug coverage.
Spectrum: Slight Partisan Bill (Republican 3-1)
Status: (Introduced - Dead) 2021-03-04 - Referred to Insurance [HB1093 Detail]
Download: Texas-2021-HB1093-Introduced.html
87R3428 JES-F | ||
By: Lucio III | H.B. No. 1093 |
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relating to the regulation of pharmacy benefit managers and health | ||
benefit plan issuers in relation to prescription drug coverage. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Chapter 1369, Insurance Code, is amended by | ||
adding Subchaper A-1 to read as follows: | ||
SUBCHAPTER A-1. COMPLAINTS | ||
Sec. 1369.021. COMPLAINTS AGAINST PHARMACY BENEFIT | ||
MANAGERS. (a) The commissioner may receive and review written | ||
complaints alleging violations of this chapter by a pharmacy | ||
benefit manager. | ||
(b) Based on review under Subsection (a), if the | ||
commissioner has reason to believe that a pharmacy benefit manager | ||
engaged in a course of conduct exhibited through a pattern or | ||
practice that violates this chapter or constitutes improper, | ||
fraudulent, or dishonest contract performance with the pharmacist | ||
or pharmacy, the commissioner may conduct any investigation | ||
necessary to determine whether the pattern or practice exists. | ||
(c) The commissioner shall take appropriate disciplinary | ||
action as provided by this code against the pharmacy benefit | ||
manager if the commissioner finds, based on an investigation | ||
authorized by Subsection (b), that the pharmacy benefit manager | ||
engaged in a course of conduct exhibited through a pattern or | ||
practice that violates this chapter or constitutes improper, | ||
fraudulent, or dishonest contract performance with the pharmacist | ||
or pharmacy. | ||
(d) The commissioner may exercise the subpoena authority | ||
under Section 36.152 in an investigation under this section. | ||
SECTION 2. Chapter 1369, Insurance Code, is amended by | ||
adding Subchapter I to read as follows: | ||
SUBCHAPTER I. RELATIONSHIP TO PHARMACISTS AND PHARMACIES | ||
Sec. 1369.551. DEFINITIONS. In this subchapter: | ||
(1) "Affiliated pharmacist of pharmacy" means a | ||
pharmacist or pharmacy that directly, or indirectly through one or | ||
more intermediaries, controls or is controlled by, or is under | ||
common control with, a pharmacy benefit manager. | ||
(2) "Pharmacy benefit manager" means a person, other | ||
than a pharmacist or pharmacy, who acts as an administrator in | ||
connection with pharmacy benefits. | ||
Sec. 1369.552. APPLICABILITY OF SUBCHAPTER. (a) This | ||
subchapter applies only to a health benefit plan that provides | ||
benefits for medical or surgical expenses incurred as a result of a | ||
health condition, accident, or sickness, including an individual, | ||
group, blanket, or franchise insurance policy or insurance | ||
agreement, a group hospital service contract, or an individual or | ||
group evidence of coverage or similar coverage document that is | ||
offered by: | ||
(1) an insurance company; | ||
(2) a group hospital service corporation operating | ||
under Chapter 842; | ||
(3) a health maintenance organization operating under | ||
Chapter 843; | ||
(4) an approved nonprofit health corporation that | ||
holds a certificate of authority under Chapter 844; | ||
(5) a multiple employer welfare arrangement that holds | ||
a certificate of authority under Chapter 846; | ||
(6) a stipulated premium company operating under | ||
Chapter 884; | ||
(7) a fraternal benefit society operating under | ||
Chapter 885; | ||
(8) a Lloyd's plan operating under Chapter 941; or | ||
(9) an exchange operating under Chapter 942. | ||
(b) Notwithstanding any other law, this subchapter applies | ||
to: | ||
(1) a small employer health benefit plan subject to | ||
Chapter 1501, including coverage provided through a health group | ||
cooperative under Subchapter B of that chapter; | ||
(2) a standard health benefit plan issued under | ||
Chapter 1507; | ||
(3) health benefits provided by or through a church | ||
benefits board under Subchapter I, Chapter 22, Business | ||
Organizations Code; | ||
(4) group health coverage made available by a school | ||
district in accordance with Section 22.004, Education Code; | ||
(5) a regional or local health care program operated | ||
under Section 75.104, Health and Safety Code; and | ||
(6) a self-funded health benefit plan sponsored by a | ||
professional employer organization under Chapter 91, Labor Code. | ||
(c) This subchapter does not apply to an issuer or provider | ||
of health benefits under or a pharmacy benefit manager | ||
administering pharmacy benefits under a workers' compensation | ||
insurance policy or other form of providing medical benefits under | ||
Title 5, Labor Code. | ||
Sec. 1369.553. REDUCTION OF CERTAIN CLAIM PAYMENT AMOUNTS | ||
PROHIBITED. (a) A health benefit plan issuer or pharmacy benefit | ||
manager may not directly or indirectly reduce the amount of a claim | ||
payment to a pharmacist or pharmacy after adjudication of the claim | ||
through the use of an aggregated effective rate, a quality | ||
assurance program, other direct or indirect remuneration fee, or | ||
otherwise, except in accordance with an audit performed under | ||
Subchapter F. | ||
(b) Nothing in this section prohibits a health benefit plan | ||
issuer or pharmacy benefit manager from increasing a claim payment | ||
amount after adjudication of the claim. | ||
(c) Notwithstanding any other law, this section applies to | ||
the Medicaid managed care program operated under Chapter 533, | ||
Government Code. | ||
Sec. 1369.554. PROFESSIONAL STANDARDS AND SCOPE OF PRACTICE | ||
REQUIREMENTS. A health benefit plan issuer or pharmacy benefit | ||
manager may not as a condition of a contract with a pharmacist or | ||
pharmacy: | ||
(1) require pharmacist or pharmacy accreditation | ||
standards or recertification requirements inconsistent with, more | ||
stringent than, or in addition to federal and state requirements; | ||
or | ||
(2) prohibit a licensed pharmacist or pharmacy from | ||
dispensing any drug, including a specialty drug, that may be | ||
dispensed under the pharmacist's or pharmacy's license unless | ||
applicable state or federal law prohibits the pharmacist or | ||
pharmacy from dispensing the drug. | ||
Sec. 1369.555. RESTRICTIONS ON MAIL ORDER PHARMACY | ||
SERVICES. A pharmacy benefit manager may not require an enrollee to | ||
use a mail order pharmacy. | ||
Sec. 1369.556. DELIVERY OF DRUGS. Except in a case in which | ||
the health benefit plan issuer or pharmacy benefit manager makes a | ||
credible allegation of fraud against the pharmacist or pharmacy and | ||
provides reasonable notice of the allegation and the basis of the | ||
allegation to the pharmacist or pharmacy, a health benefit plan | ||
issuer or pharmacy benefit manager may not as a condition of a | ||
contract with a pharmacist or pharmacy prohibit the pharmacist or | ||
pharmacy from: | ||
(1) mailing or delivering a drug to a patient on the | ||
patient's request, to the extent permitted by law; or | ||
(2) charging a shipping and handling fee to a patient | ||
requesting a prescription be mailed or delivered if the pharmacist | ||
or pharmacy discloses to the patient before the delivery: | ||
(A) the fee that will be charged; and | ||
(B) that the fee may not be reimbursable by the | ||
health benefit plan issuer or pharmacy benefit manager. | ||
Sec. 1369.557. PROHIBITION ON CERTAIN REFERRALS. (a) A | ||
health benefit plan issuer or pharmacy benefit manager may not | ||
steer or direct a patient to use an affiliated pharmacist or | ||
pharmacy through: | ||
(1) any oral or written communication, including: | ||
(A) online messaging regarding the pharmacist or | ||
pharmacy; or | ||
(B) patient- or prospective patient-specific | ||
advertising, marketing, or promotion of the pharmacist or pharmacy; | ||
or | ||
(2) offering or implementing a health benefit plan | ||
design that requires or induces a patient to use an affiliated | ||
pharmacist or pharmacy, including by providing for reduced | ||
cost-sharing amounts if the patient uses the pharmacist or | ||
pharmacy. | ||
(b) This section does not prohibit a health benefit plan | ||
issuer or pharmacy benefit manager from including an affiliated | ||
pharmacist or pharmacy in the issuer's or manager's patient | ||
communications, including in a patient- or prospective | ||
patient-specific communication, if the communication: | ||
(1) is regarding in-network pharmacies and prices for | ||
a health benefit plan; | ||
(2) is accurate; and | ||
(3) includes in-network pharmacists or pharmacies | ||
that are not affiliated pharmacists or pharmacies. | ||
(c) An affiliated pharmacist or pharmacy may not present a | ||
claim for payment to any individual or entity, including to a | ||
third-party payor, health benefit plan, or pharmacy benefit | ||
manager, for a health care service or supply provided to a patient | ||
who was improperly steered or directed to use the affiliated | ||
pharmacist or pharmacy in violation of Subsection (a). | ||
Sec. 1369.558. PROHIBITION ON SHARING PATIENT INFORMATION | ||
FOR CERTAIN PURPOSES. (a) In this section, "commercial purpose" | ||
does not include pharmacy reimbursement, formulary compliance, | ||
pharmaceutical care, utilization review by a health care provider, | ||
or a public health activity authorized by law. | ||
(b) A health benefit plan issuer or pharmacy benefit manager | ||
may not transfer to or receive from an affiliated pharmacist or | ||
pharmacy a record containing patient- or prescriber-identifiable | ||
prescription information for a commercial purpose. | ||
SECTION 3. The change in law made 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 4. This Act takes effect September 1, 2021. |