The text as introduced · 1,259 words
89R11480 SCF-D
By: Hughes
S.B. No. 1236
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.
Monitoring 
