bill setting a floor for Medicaid pharmacy payments

The text as introduced · 616 words

89R4791 JG-F

By: Oliverson
H.B. No. 4533

A BILL TO BE ENTITLED

AN ACT

relating to the reimbursement of prescription drugs under Medicaid

and the child health plan program.

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

SECTION 1. Subchapter F, Chapter 540, Government Code, as

effective April 1, 2025, is amended by adding Section 540.02731 to

read as follows:

Sec. 540.02731. PHARMACY BENEFIT PLAN: REIMBURSEMENT

METHODOLOGY FOR PRESCRIPTION DRUGS; STUDY. (a) Notwithstanding

any other law and in accordance with rules the executive

commissioner adopts, a Medicaid managed care organization or a

pharmacy benefit manager administering a pharmacy benefit program

on behalf of the organization shall reimburse a pharmacy or

pharmacist, including a Texas retail pharmacy or a Texas specialty

pharmacy, that dispenses a prescribed prescription drug to a

recipient an amount that is not less than the lesser of:

(1) the reimbursement amount for the drug under the

vendor drug program, including a dispensing fee that is not less

than the dispensing fee for the drug under the vendor drug program;

or

(2) the amount claimed by the pharmacy or pharmacist,

including the gross amount due or the usual and customary charge to

the public for the drug.

(b) The methodology the executive commissioner adopts by

rule to determine Texas pharmacies' actual acquisition cost (AAC)

for purposes of the vendor drug program must be consistent with the

actual prices Texas retail pharmacies, Texas specialty pharmacies,

and Texas long-term care pharmacies, as applicable, pay to acquire

prescription drugs.

(c) The executive commissioner shall develop a process for

determining Texas pharmacies' actual acquisition cost (AAC) for

prescription drugs that:

(1) to the extent possible, bases the cost on cost data

obtained from surveys of Texas pharmacies, including retail,

specialty, and long-term care pharmacies, conducted by the

commission on at least a monthly basis; and

(2) uses an alternative method for determining the

cost with respect to prescription drugs for which insufficient cost

data is available from surveys conducted under Subdivision (1).

(d) The executive commissioner may require Texas pharmacies

to respond or submit information in response to surveys described

by Subsection (c)(1) as a condition of participation as a Medicaid

provider.

(e) The dispensing fees the executive commissioner adopts

under Subsection (a) must be based on, as appropriate:

(1) Texas retail pharmacies' professional dispensing

costs for retail prescription drugs; or

(2) Texas specialty pharmacies' professional

dispensing costs for specialty prescription drugs.

(f) At least once every two years, the commission shall

conduct a study of Texas pharmacies' dispensing costs for retail

prescription drugs and specialty prescription drugs. Based on the

results of the study, the executive commissioner shall adjust the

minimum amount of the retail pharmacy professional dispensing fee

and specialty pharmacy professional dispensing fee under

Subsection (a).

(g) A contract to which this subchapter applies must require

the contracting Medicaid managed care organization and any

subcontracted pharmacy benefit manager to comply with Subsection

(a).

SECTION 2. Subchapter D, Chapter 62, Health and Safety

Code, is amended by adding Section 62.160 to read as follows:

Sec. 62.160. PHARMACY BENEFIT PLAN: REIMBURSEMENT

METHODOLOGY FOR PRESCRIPTION DRUGS. A managed care organization

providing pharmacy benefits under the child health plan program or

a pharmacy benefit manager administering a pharmacy benefit program

on behalf of the organization shall comply with Section 540.02731,

Government Code.

SECTION 3. If before implementing any provision of this Act

a state agency determines that a waiver or authorization from a

federal agency is necessary for implementation of that provision,

the agency affected by the provision shall request the waiver or

authorization and may delay implementing that provision until the

waiver or authorization is granted.

SECTION 4. This Act takes effect March 1, 2026.