Bill Text: TX HB778 | 2015-2016 | 84th Legislature | Introduced
Bill Title: Relating to access to pharmacists, pharmacies, and pharmaceutical care under certain health benefit plans.
Spectrum: Partisan Bill (Republican 3-0)
Status: (Introduced - Dead) 2015-03-11 - Left pending in committee [HB778 Detail]
Download: Texas-2015-HB778-Introduced.html
84R1613 PMO-F | ||
By: Bell | H.B. No. 778 |
|
||
|
||
relating to access to pharmacists, pharmacies, and pharmaceutical | ||
care under certain health benefit plans. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Chapter 1451, Insurance Code, is amended by | ||
adding Subchapter K to read as follows: | ||
SUBCHAPTER K. ACCESS TO PHARMACIES, PHARMACISTS, AND | ||
PHARMACEUTICAL CARE | ||
Sec. 1451.501. DEFINITIONS. In this subchapter: | ||
(1) "Drug," "pharmaceutical care," "pharmacist," | ||
"pharmacy," and "prescription drug" have the meanings assigned by | ||
Section 551.003, Occupations Code. | ||
(2) "Enrollee" means an individual who is covered | ||
under a health benefit plan, including a covered dependent. | ||
(3) "Pharmacy benefit manager" has the meaning | ||
assigned by Section 4151.151. | ||
Sec. 1451.502. APPLICABILITY OF SUBCHAPTER. (a) Except as | ||
provided by Section 1451.503, this subchapter applies only to a | ||
health benefit plan that provides benefits for medical, surgical, | ||
or other treatment expenses incurred as a result of a health | ||
condition, an accident, sickness, or substance abuse, 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 provision in Chapter 1551, 1575, | ||
1579, or 1601 or any other law, this chapter applies to health | ||
benefit plan coverage provided under: | ||
(1) Chapter 1551; | ||
(2) Chapter 1575; | ||
(3) Chapter 1579; and | ||
(4) Chapter 1601. | ||
(c) Notwithstanding Section 1501.251 or any other law, this | ||
chapter applies to coverage under a small employer health benefit | ||
plan subject to Chapter 1501. | ||
Sec. 1451.503. EXCEPTION TO APPLICABILITY OF SUBCHAPTER. | ||
This subchapter does not apply to a self-insured, self-funded, or | ||
other employee welfare benefit plan that is exempt from state | ||
regulation under the Employee Retirement Income Security Act of | ||
1974 (29 U.S.C. Section 1001 et seq.). | ||
Sec. 1451.504. SELECTION OF PHARMACIST AND PHARMACY. A | ||
health benefit plan issuer or a pharmacy benefit manager | ||
administering pharmacy benefits under a health benefit plan may | ||
not: | ||
(1) prohibit or limit an enrollee from selecting a | ||
pharmacist or pharmacy of the enrollee's choice to furnish | ||
prescription drugs or pharmaceutical care covered by the health | ||
benefit plan; or | ||
(2) interfere with an enrollee's selection of a | ||
pharmacist or pharmacy to furnish prescription drugs or | ||
pharmaceutical care covered by the health benefit plan. | ||
Sec. 1451.505. PARTICIPATION OF PHARMACISTS AND | ||
PHARMACIES. (a) Subject to Subsection (b), a health benefit plan | ||
issuer or a pharmacy benefit manager administering pharmacy | ||
benefits under a health benefit plan may not deny a pharmacist or | ||
pharmacy the right to participate as a provider or preferred | ||
provider, as applicable, under the health benefit plan if the | ||
pharmacist or pharmacy agrees to: | ||
(1) provide prescription drugs and pharmaceutical | ||
care in accordance with the terms of the health benefit plan; and | ||
(2) accept the administrative, financial, and | ||
professional conditions that apply to pharmacists and pharmacies | ||
who have been designated by the health benefit plan or the pharmacy | ||
benefit manager as providers or preferred providers, as applicable, | ||
under the health benefit plan. | ||
(b) The conditions described by Subsection (a)(2) must be | ||
applied uniformly to all pharmacists and pharmacies who have been | ||
designated by the health benefit plan or the pharmacy benefit | ||
manager as providers or preferred providers, as applicable, under | ||
the health benefit plan. | ||
Sec. 1451.506. MANDATORY PARTICIPATION PROHIBITED. A | ||
health benefit plan issuer or a pharmacy benefit manager | ||
administering pharmacy benefits under a health benefit plan may not | ||
require a pharmacist or pharmacy to participate as a provider or | ||
preferred provider under a health benefit plan as a condition of | ||
participating as a provider or preferred provider under another | ||
health benefit plan. | ||
Sec. 1451.507. DOSAGE AND QUANTITY REQUIREMENTS. (a) A | ||
health benefit plan issuer or a pharmacy benefit manager | ||
administering pharmacy benefits under a health benefit plan may not | ||
require an enrollee to obtain or request a specific quantity or | ||
dosage supply of prescription drugs. | ||
(b) Notwithstanding Subsection (a), an enrollee's physician | ||
or other prescribing health care provider may prescribe | ||
prescription drugs in a quantity or dosage supply the physician or | ||
provider determines appropriate and that is in compliance with | ||
state and federal statutes. | ||
Sec. 1451.508. COST SAVING MEASURES ALLOWED. (a) Subject | ||
to Subsection (b), this subchapter does not prohibit a health | ||
benefit plan issuer or pharmacy benefit manager administering | ||
pharmacy benefits under a health benefit plan from, in an effort to | ||
achieve cost savings to the health benefit plan or the enrollee: | ||
(1) limiting the quantity or dosage supply of a drug | ||
covered under the plan; or | ||
(2) providing a financial incentive to encourage an | ||
enrollee or physician or other prescribing health care provider to | ||
use certain drugs in certain quantities. | ||
(b) The quantity or dosage limitations and the financial | ||
incentives described by Subsection (a) must be applied or provided | ||
uniformly to all pharmacists and pharmacies who have been | ||
designated by the health benefit plan or pharmacy benefit manager | ||
as providers or preferred providers, as applicable, under the | ||
health benefit plan. | ||
Sec. 1451.509. PHARMACY BENEFIT CARD PROGRAM. This | ||
subchapter does not prohibit a health benefit plan issuer or | ||
pharmacy benefit manager administering pharmacy benefits under a | ||
health benefit plan from establishing or administering a pharmacy | ||
benefit card program that is a "discount health care program" for | ||
purposes of Chapter 562 that authorizes an enrollee to obtain | ||
prescription drugs and pharmaceutical care from designated | ||
providers. | ||
Sec. 1451.510. APPLICATION AND RENEWAL FEES. This | ||
subchapter does not prohibit a health benefit plan issuer or | ||
pharmacy benefit manager administering pharmacy benefits under a | ||
health benefit plan from establishing reasonable and uniform | ||
application and renewal fees for a pharmacist or pharmacy to | ||
participate as a provider or preferred provider, as applicable, | ||
under the health benefit plan. | ||
Sec. 1451.511. COVERAGE NOT REQUIRED. This subchapter does | ||
not require a health benefit plan to provide coverage for drugs or | ||
pharmaceutical care. | ||
Sec. 1451.512. CONFLICTING CONTRACT PROVISION VOID. A | ||
provision of a health benefit plan or of a contract with a pharmacy | ||
benefit manager that conflicts with this subchapter is void to the | ||
extent of the conflict. | ||
Sec. 1451.513. INJUNCTIVE RELIEF. A pharmacist, pharmacy, | ||
or enrollee adversely affected by a violation of this subchapter | ||
may bring suit in district court for injunctive relief to enforce | ||
this subchapter. | ||
Sec. 1451.514. DEPARTMENT MONITORING. The commissioner | ||
shall monitor health benefit plans and pharmacy benefit managers to | ||
ensure compliance with this subchapter. | ||
SECTION 2. Section 843.303(b), Insurance Code, is amended | ||
to read as follows: | ||
(b) Unless otherwise limited by Subchapter K, Chapter 1451 | ||
[ |
||
maintenance organization from rejecting an initial application | ||
from a physician or provider based on the determination that the | ||
plan has sufficient qualified physicians or providers. | ||
SECTION 3. Section 843.304(c), Insurance Code, is amended | ||
to read as follows: | ||
(c) This section does not require that a health maintenance | ||
organization: | ||
(1) use a particular type of provider in its | ||
operation; | ||
(2) accept each provider of a category or type, except | ||
as provided by Subchapter K, Chapter 1451 [ |
||
(3) contract directly with providers of a particular | ||
category or type. | ||
SECTION 4. Article 21.52B, Insurance Code, is repealed. | ||
SECTION 5. This Act applies only to a health benefit plan | ||
that is delivered, issued for delivery, or renewed on or after | ||
January 1, 2016. A health benefit plan delivered, issued for | ||
delivery, or renewed before January 1, 2016, 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 6. This Act takes effect September 1, 2015. |