Bill Text: TX HB1763 | 2021-2022 | 87th Legislature | Enrolled


Bill Title: Relating to the contractual relationship between a pharmacist or pharmacy and a health benefit plan issuer or pharmacy benefit manager.

Spectrum: Slight Partisan Bill (Republican 26-15)

Status: (Passed) 2021-05-26 - Effective on 9/1/21 [HB1763 Detail]

Download: Texas-2021-HB1763-Enrolled.html
 
 
  H.B. No. 1763
 
 
 
 
AN ACT
  relating to the contractual relationship between a pharmacist or
  pharmacy and a health benefit plan issuer or pharmacy benefit
  manager.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Chapter 1369, Insurance Code, is amended by
  adding Subchapter L to read as follows:
  SUBCHAPTER L. CONTRACTS WITH PHARMACISTS AND PHARMACIES
         Sec. 1369.551.  DEFINITIONS. In this subchapter:
               (1)  "Pharmacy benefit manager" has the meaning
  assigned by Section 4151.151.
               (2)  "Pharmacy benefit network" means a network of
  pharmacies that have contracted with a pharmacy benefit manager to
  provide pharmacist services to enrollees.
               (3)  "Pharmacy services administrative organization"
  means an entity that contracts with a pharmacist or pharmacy to
  conduct on behalf of the pharmacist or pharmacy the pharmacist's or
  pharmacy's business with a third-party payor, including a pharmacy
  benefit manager, in connection with pharmacy benefits and to assist
  the pharmacist or pharmacy by providing administrative services,
  including negotiating, executing, and administering a contract
  with a third-party payor and communicating with the third-party
  payor in connection with a contract or 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, 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.
         Sec. 1369.554.  REIMBURSEMENT OF AFFILIATED AND
  NONAFFILIATED PHARMACISTS AND PHARMACIES. (a) In this section:
               (1)  "Affiliated pharmacist or 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)  "Nonaffiliated pharmacist or pharmacy" means a
  pharmacist or pharmacy that does not directly, or indirectly
  through one or more intermediaries, control and is not controlled
  by or under common control with a pharmacy benefit manager.
         (b)  A pharmacy benefit manager may not pay an affiliated
  pharmacist or pharmacy a reimbursement amount that is more than the
  amount the pharmacy benefit manager pays a nonaffiliated pharmacist
  or pharmacy for the same pharmacist service.
         Sec. 1369.555.  NETWORK CONTRACT FEE SCHEDULE. A pharmacy
  benefit network contract must 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.
         Sec. 1369.556.  DISCLOSURE OF PHARMACY SERVICES
  ADMINISTRATIVE ORGANIZATION CONTRACT. A pharmacist or pharmacy
  that is a member of a pharmacy services administrative organization
  that enters into a contract with a health benefit plan issuer or
  pharmacy benefit manager on the pharmacist's or pharmacy's behalf
  is entitled to receive from the pharmacy services administrative
  organization a copy of the contract provisions applicable to the
  pharmacist or pharmacy, including each provision relating to the
  pharmacist's or pharmacy's rights and obligations under the
  contract.
         Sec. 1369.557.  DELIVERY OF DRUGS. (a) 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.
         (b)  A pharmacist or pharmacy may not charge a health benefit
  plan issuer or pharmacy benefit manager for the delivery of a
  prescription drug as described by this section unless the charge is
  specifically agreed to by the health benefit plan issuer or
  pharmacy benefit manager.
         Sec. 1369.558.  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 that may be dispensed under the pharmacist's or
  pharmacy's license unless:
                     (A)  applicable state or federal law prohibits the
  pharmacist or pharmacy from dispensing the drug; or
                     (B)  the manufacturer of the drug requires that a
  pharmacist or pharmacy possess one or more accreditations or
  certifications to dispense the drug and the pharmacist or pharmacy
  does not meet the requirement.
         Sec. 1369.559.  RETALIATION PROHIBITED. (a) A pharmacy
  benefit manager may not retaliate against a pharmacist or pharmacy
  based on the pharmacist's or pharmacy's exercise of any right or
  remedy under this chapter. Retaliation prohibited by this section
  includes:
               (1)  terminating or refusing to renew a contract with
  the pharmacist or pharmacy;
               (2)  subjecting the pharmacist or pharmacy to increased
  audits; or
               (3)  failing to promptly pay the pharmacist or pharmacy
  any money owed by the pharmacy benefit manager to the pharmacist or
  pharmacy.
         (b)  For purposes of this section, a pharmacy benefit manager
  is not considered to have retaliated against a pharmacist or
  pharmacy if the pharmacy benefit manager:
               (1)  takes an action in response to a credible
  allegation of fraud against the pharmacist or pharmacy; and
               (2)  provides reasonable notice to the pharmacist or
  pharmacy of the allegation of fraud and the basis of the allegation
  before taking the action.
         Sec. 1369.560.  WAIVER PROHIBITED. The provisions of this
  subchapter may not be waived, voided, or nullified by contract.
         SECTION 2.  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 3.  This Act takes effect September 1, 2021.
 
 
  ______________________________ ______________________________
     President of the Senate Speaker of the House     
 
 
         I certify that H.B. No. 1763 was passed by the House on April
  27, 2021, by the following vote:  Yeas 147, Nays 0, 1 present, not
  voting.
 
  ______________________________
  Chief Clerk of the House   
 
 
         I certify that H.B. No. 1763 was passed by the Senate on May
  13, 2021, by the following vote:  Yeas 30, Nays 0.
 
  ______________________________
  Secretary of the Senate    
  APPROVED:  _____________________
                     Date          
   
            _____________________
                   Governor       
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