Hughes’s bill setting minimum pharmacy reimbursement

The text as introduced · 1,191 words

89R6156 SCL-D

By: Hughes
S.B. No. 1354

A BILL TO BE ENTITLED

AN ACT

relating to the minimum reimbursement amount for prescription drugs

and devices to health benefit plan network pharmacists and

pharmacies.

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

SECTION 1. Chapter 1369, Insurance Code, is amended by

adding Subchapter H-1 to read as follows:

SUBCHAPTER H-1. MINIMUM REIMBURSEMENT AMOUNT FOR NETWORK

PHARMACISTS AND PHARMACIES

Sec. 1369.371. DEFINITIONS. In this subchapter:

(1) "Health benefit plan" has the meaning assigned by

Section 1369.251.

(2) "Pharmacy benefit manager" means:

(A) a pharmacy benefit manager, as defined by

Section 4151.151; or

(B) a health benefit plan issuer or sponsor that

administers pharmacy benefits in connection with the health benefit

plan.

Sec. 1369.372. APPLICABILITY OF SUBCHAPTER. This

subchapter applies to the administration of pharmacy benefits by or

on behalf of an issuer or sponsor of a health benefit plan.

Sec. 1369.373. 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, including the Medicaid

managed care program operated under Chapter 540, Government Code;

(2) the child health plan program under Chapter 62,

Health and Safety Code;

(3) the TRICARE military health system;

(4) a basic coverage plan under Chapter 1551;

(5) a basic plan under Chapter 1575;

(6) a coverage plan under Chapter 1579;

(7) a plan providing basic coverage under Chapter

1601; or

(8) a workers' compensation insurance policy or other

form of providing medical benefits under Title 5, Labor Code.

Sec. 1369.374. REIMBURSEMENT MINIMUM; DISPENSING FEES.

(a) Notwithstanding any other law and subject to Subsection (c), a

pharmacy benefit manager may not reimburse a pharmacist or pharmacy

under contract with the pharmacy benefit manager for a prescription

drug or device an amount that is less than the actual cost to that

pharmacist or pharmacy for the drug or device.

(b) Subsection (a) does not apply to a pharmacy benefit

manager using an ingredient cost reimbursement methodology for a

prescription drug or device that is identical to the reimbursement

methodology for the ingredient cost of the drug or device under the

Medicaid fee-for-service model.

(c) In calculating the reimbursement amount for a

prescription drug or device under Subsection (a), a pharmacy

benefit manager may not include in that calculation the amount of a

professional dispensing fee payable to the pharmacist or pharmacy

that dispensed the drug or device.

(d) A pharmacy benefit manager shall reimburse a pharmacist

or pharmacy under contract with the pharmacy benefit manager a

professional dispensing fee for a prescription drug or device in an

amount that is not less than the amount of the dispensing fee paid

for the drug or device under the Medicaid fee-for-service model.

Sec. 1369.375. APPEAL: PROCEDURES REQUIRED. (a) A

pharmacy benefit manager shall provide in the contract with each

pharmacist or pharmacy a procedure for the pharmacist or pharmacy

to appeal a reimbursement of a prescription drug or device that the

pharmacist or pharmacy alleges to not be in compliance with Section

1369.374 on or before the seventh day after the date the

reimbursement is provided.

(b) The appeal procedure provision must:

(1) be approved by the commissioner; and

(2) permit a pharmacist or pharmacy or the

pharmacist's or pharmacy's designated agent to file an appeal using

the standard appeal form described by Subsection (d).

(c) A pharmacy benefit manager shall file an appeal

procedure provision with the department in the form and manner

prescribed by the commissioner.

(d) The commissioner shall develop and make available to

pharmacy benefit managers a standard appeal form to be used to file

an appeal of a reimbursement alleged to not be in compliance with

Section 1369.374.

Sec. 1369.376. APPEAL: PHARMACIST OR PHARMACY AGENT. A

pharmacist or pharmacy electing to appeal a reimbursement under a

procedure described by Section 1369.375 may designate a pharmacy

services administrative organization or another agent to file and

conduct the appeal.

Sec. 1369.377. APPEAL: EFFECT OF PHARMACIST OR PHARMACY

PREVAILING. (a) In this section, "similarly situated pharmacist

or pharmacy" means a pharmacist or pharmacy:

(1) that is under contract with the pharmacy benefit

manager;

(2) that purchases the prescription drug or device

that is the subject of an appeal of a reimbursement not in

compliance with Section 1369.374 from the same pharmaceutical

wholesaler as the pharmacist or pharmacy that prevailed in the

appeal; and

(3) to which the pharmacy benefit manager also applies

the challenged reimbursement rate or actual cost for the

prescription drug or device.

(b) If a pharmacist or pharmacy prevails in an appeal of a

reimbursement alleged to not be in compliance with Section

1369.374, the pharmacy benefit manager shall, not later than the

seventh day after the date the pharmacist or pharmacy prevailed:

(1) make the necessary change to the challenged

reimbursement or actual cost;

(2) if the product involved in the appeal is a

prescription drug, provide the pharmacist or pharmacy the national

drug code number for the drug;

(3) permit the pharmacist or pharmacy to reverse and

rebill the claim that is the subject of the appeal;

(4) pay or waive any transaction fee required to

reverse or rebill the claim;

(5) reimburse the pharmacist or pharmacy at least the

pharmacist's or pharmacy's actual cost for the prescription drug or

device; and

(6) apply the findings from the appeal to the

reimbursement rate and actual cost for the prescription drug or

device that is the subject of the appeal to other similarly situated

pharmacists and pharmacies.

Sec. 1369.378. APPEAL: EFFECT OF PHARMACY BENEFIT MANAGER

PREVAILING. (a) If a pharmacy benefit manager prevails in an

appeal of a reimbursement alleged to not be in compliance with

Section 1369.374 and the prescription drug or device that is the

subject of the appeal is available at a cost equal to or less than

the challenged reimbursement, the pharmacy benefit manager shall,

not later than the seventh day after the date the pharmacy benefit

manager prevails:

(1) provide the pharmacist or pharmacy with the name

of the national or regional pharmaceutical wholesaler operating in

this state that has the drug or device in stock at a price that is

equal to or less than the challenged reimbursement; and

(2) as applicable, provide the national drug code

number for the drug or the unique device identifier for the device.

(b) If a pharmacy benefit manager fails to comply with

Subsection (a), the pharmacy benefit manager shall:

(1) adjust the challenged reimbursement to an amount

equal to or greater than the pharmacist's or pharmacy's actual cost;

(2) permit the pharmacist or pharmacy to reverse and

rebill each claim affected by the inability to obtain the drug or

device at a cost equal to or less than the challenged reimbursement;

and

(3) pay or waive any transaction fee required to

reverse and rebill each affected claim.

SECTION 2. Subchapter H-1, Chapter 1369, Insurance Code, as

added by this Act, applies only to a health benefit plan delivered,

issued for delivery, or renewed on or after January 1, 2026.

SECTION 3. This Act takes effect September 1, 2025.