Hefner’s bill limiting how benefit managers treat pharmacies

The text as introduced · 1,259 words

89R11480 SCF-D

By: Hefner
H.B. No. 3317

A BILL TO BE ENTITLED

AN ACT

relating to the relationship between pharmacists or pharmacies and

health benefit plan issuers or pharmacy benefit managers.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Section 1369.153, Insurance Code, is amended by

adding Subsection (e) to read as follows:

(e) The commissioner by rule shall require a health benefit

plan that provides pharmacy benefits to enrollees to include on the

front of the identification card of each enrollee a unique

identifier that enables a pharmacist or pharmacy to determine when

submitting a claim that the enrollee's health benefit plan or

pharmacy benefit plan is subject to regulation by the department.

For purposes of this subsection, the commissioner may require a

unique bank identification number, processor control number, or

group number.

SECTION 2. Section 1369.252, Insurance Code, is amended to

read as follows:

Sec. 1369.252. EXCEPTIONS TO APPLICABILITY OF SUBCHAPTER.

This subchapter does not apply to an issuer or provider of health

benefits under or a pharmacy benefit manager administering pharmacy

benefits under:

(1) the state Medicaid program;

(2) the federal Medicare program;

(3) the state child health plan or health benefits

plan for children under Chapter 62 or 63, Health and Safety Code;

(4) the TRICARE military health system; or

(5) a workers' compensation insurance policy or other

form of providing medical benefits under Title 5, Labor Code[ ; or

[ (6) a self-funded health benefit plan as defined by

the Employee Retirement Income Security Act of 1974 (29 U.S.C.

Section 1001 et seq.) ].

SECTION 3. The heading to Section 1369.259, Insurance Code,

is amended to read as follows:

Sec. 1369.259. LIMITATIONS ON PAYMENT ADJUSTMENTS AND

[ CALCULATION OF ] RECOUPMENT; USE OF EXTRAPOLATION PROHIBITED.

SECTION 4. Section 1369.259, Insurance Code, is amended by

adding Subsections (a-1) and (e) to read as follows:

(a-1) A health benefit plan issuer or pharmacy benefit

manager may not, as the result of an audit, deny or reduce a claim

payment made to a pharmacist or pharmacy after adjudication of the

claim unless:

(1) the original claim was submitted fraudulently;

(2) the original claim payment was incorrect because

the pharmacist or pharmacy had already been paid for the pharmacist

service; or

(3) the pharmacist or pharmacy made a substantive

non-clerical or non-recordkeeping error that led to the patient

receiving the wrong prescription drug or dosage.

(e) Except for a claim described by Subsection (a-1), a

health benefit plan issuer or pharmacy benefit manager:

(1) may only recoup the dispensing fee paid by the

health benefit plan issuer or pharmacy benefit manager to the

pharmacist or pharmacy associated with the audited claim; and

(2) may not recoup from the pharmacist or pharmacy the

cost of the drug or any other amount related to the claim.

SECTION 5. Subchapter M, Chapter 1369, Insurance Code, is

amended by adding Sections 1369.6021, 1369.6022, 1369.6023,

1369.6024, and 1369.6025 to read as follows:

Sec. 1369.6021. ONLINE ACCESS TO PHARMACY BENEFIT NETWORK

CONTRACT. A health benefit plan issuer or pharmacy benefit manager

shall make available to any pharmacist or pharmacy in the issuer's

or manager's pharmacy benefit network access to a secure, online

portal through which the pharmacist or pharmacy may access all

pharmacy benefit network contracts between the health benefit plan

issuer or pharmacy benefit manager and the pharmacist or pharmacy,

including any contract addendums.

Sec. 1369.6022. PHARMACY BENEFIT NETWORK CONTRACT

MODIFICATIONS AND ADDENDUMS. (a) A pharmacist or pharmacy must

have an opportunity to refuse a proposed modification or addendum

to a pharmacy benefit network contract. A proposed modification or

addendum may not take effect without the signed approval of the

pharmacist or pharmacy.

(b) A health benefit plan issuer or pharmacy benefit manager

must, not later than the 90th day before the date a proposed

modification or addendum to a pharmacy benefit network contract is

to take effect:

(1) post the proposed modification or addendum to the

online portal described by Section 1369.6021; and

(2) provide to the pharmacist or pharmacy notice of

the proposed modification or addendum by e-mail, including:

(A) a link to the online portal;

(B) the National Council for Prescription Drug

Programs number or other identifier approved by the commissioner

for the pharmacist or pharmacy to which the proposed modification

or addendum applies; and

(C) a description of the proposed modification or

addendum in a manner that allows the pharmacist or pharmacy to

compare the proposed modification or addendum to the current

contract.

(c) A pharmacy benefit network contract may not incorporate

by reference a document not included in a contract or contract

attachment, including a provider manual. All financial terms,

including reimbursement rates and methodology, must be set forth in

the contract.

Sec. 1369.6023. PHARMACY BENEFIT NETWORK CONTRACT

DISCLOSURE. A pharmacy benefit network contract must state that

the contract is subject to this chapter and any rules adopted by the

commissioner under this chapter.

Sec. 1369.6024. PHARMACY BENEFIT NETWORK CONTRACT FEE

LIMITATIONS. (a) A health benefit plan issuer or pharmacy benefit

manager may not charge a fee, including an application or

participation fee, before providing a pharmacist or pharmacy with

the full proposed pharmacy benefit network contract, including any

financial terms applicable to the contract and corresponding

pharmacy benefit network.

(b) A health benefit plan issuer or pharmacy benefit manager

may not charge a pharmacist or pharmacy already participating in

the pharmacy benefit network a fee related to re-credentialing or

re-enrollment or a similar fee.

Sec. 1369.6025. PHARMACY BENEFIT NETWORK PARTICIPATION

REQUIREMENTS PROHIBITED. A health benefit plan issuer or pharmacy

benefit manager may not:

(1) require a pharmacist or pharmacy to participate in

a pharmacy benefit network;

(2) condition a pharmacist's or pharmacy's

participation in a pharmacy benefit network on participation in any

other pharmacy benefit network; or

(3) penalize a pharmacist or pharmacy for refusing to

participate in a pharmacy benefit network.

SECTION 6. Section 1369.605, Insurance Code, is amended to

read as follows:

Sec. 1369.605. NETWORK CONTRACT FEE SCHEDULE. A pharmacy

benefit network contract must include [ 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.

SECTION 7. Section 1369.259(d), Insurance Code, is

repealed.

SECTION 8. (a) Section 1369.153, Insurance Code, as

amended by this Act, applies only to a health benefit plan

delivered, issued for delivery, or renewed on or after January 1,

2026. A health benefit plan delivered, issued for delivery, or

renewed before January 1, 2026, 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.

(b) Chapter 1369, Insurance Code, as amended 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 9. This Act takes effect September 1, 2025.