HB3317 - Relating to the relationship between pharmacists or pharmacies and health benefit plan issuers or pharmacy benefit managers.

  89R23465 SCF-D     By: Hefner H.B. No. 3317     Substitute the following for H.B. No. 3317:     By:  Dean C.S.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)     A group number on an identification card provided to an   enrollee in a health benefit plan to which this subchapter applies   may be assigned only to enrollees in a health benefit plan to which   this subchapter applies.          SECTION 2.  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 3.  Section 1369.259, Insurance Code, is amended by   adding Subsections (a-1), (e), and (f) to read as follows:           (a-1)     Subject to Subsections (e) and (f), 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.           (e)     A health benefit plan issuer or pharmacy benefit manager   may recoup from a pharmacist or pharmacy the cost of a prescription   drug and the dispensing fee for the drug if:                 (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   nonclerical or non-recordkeeping error that led to the patient   receiving the wrong prescription drug or dosage.           (f)     A health benefit plan issuer or pharmacy benefit manager   may recoup only the dispensing fee from a pharmacist or pharmacy if   the pharmacist or pharmacy made a clerical error that led to an   overpayment.          SECTION 4.  Subchapter M, Chapter 1369, Insurance Code, is   amended by adding Sections 1369.6021, 1369.6022, 1369.6023,   1369.6024, 1369.6025, 1369.6026, and 1369.6027 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: ADVERSE   MATERIAL CHANGES. (a)   In this section, "adverse material change"   means a modification or addendum to a pharmacy benefit network   contract that would decrease a pharmacist's or pharmacy's payment   or compensation, change the pharmacist's or pharmacy's tier to a   less preferred tier, or change the administrative procedures in a   way that may reasonably be expected to increase the pharmacist's or   pharmacy's administrative expenses or decrease the pharmacist's or   pharmacy's payment or compensation.   The term does not include:                 (1)     a decrease in payment or compensation resulting   solely from a change in a published governmental fee schedule on   which the payment or compensation is based if the applicability of   the schedule is clearly identified in the contract;                 (2)     a decrease in payment or compensation that was   anticipated under the terms of the contract, if the amount and date   of applicability of the decrease is clearly identified in the   contract;                 (3)     an administrative change that may increase the   pharmacist's or pharmacy's administrative expenses, the specific   applicability of which is clearly identified in the contract;                 (4)  a change that is required by federal or state law;                 (5)  a termination for cause; or                 (6)     a termination without cause at the end of the term   of the contract.           (b)     A health benefit plan issuer or pharmacy benefit manager   may make an adverse material change to a pharmacy benefit network   contract during the term of the contract only with the mutual   agreement of the parties.   A provision in the contract that allows a   health benefit plan issuer or pharmacy benefit manager to   unilaterally make an adverse material change during the term of the   contract is void and unenforceable.           (c)     An adverse material change to a pharmacy benefit network   contract may not go into effect until the 120th day after the date   the pharmacist or pharmacy affirmatively agrees to the adverse   material change in writing.           (d)     An adverse material change to a pharmacy benefit network   contract proposed by a health benefit plan issuer or pharmacy   benefit manager must include notice that clearly and conspicuously   states that a pharmacist or pharmacy may choose to not agree to the   adverse material change and that the decision to not agree to the   adverse material change does not affect:                 (1)     the terms of the pharmacist's or pharmacy's   existing contract with the health benefit plan issuer or pharmacy   benefit manager; or                 (2)     the pharmacist's or pharmacy's participation in   another pharmacy benefit network.           (e)     A pharmacist's or pharmacy's decision to not agree to an   adverse material change to a pharmacy benefit network contract does   not affect:                 (1)     the terms of the pharmacist's or pharmacy's   existing contract; or                 (2)     the pharmacist's or pharmacy's participation in   another pharmacy benefit network.           (f)     A health benefit plan issuer's or pharmacy benefit   manager's failure to include the notice described by Subsection (d)   with the proposed adverse material change makes an otherwise   agreed-to adverse material change void and unenforceable.           (g)  This section does not apply to:                 (1)  a pharmacy benefit network contract:                       (A)  with an unspecified and indefinite duration;                       (B)     with no stated or automatic renewal period or   event; and                       (C)     that may only be terminated by notice from   one party to the other; or                 (2)     a proposed modification or addendum to a pharmacy   benefit network contract that is required by state or federal law or   rule.           Sec.   1369.6023.     PHARMACY BENEFIT NETWORK CONTRACT: OTHER   MODIFICATIONS AND ADDENDUMS.   (a)   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, other than an adverse material change as defined   by Section 1369.6022, 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.           (b)     If a pharmacist or pharmacy does not respond before the   31st day after the date the pharmacist or pharmacy receives notice   of a proposed modification or addendum under Subsection (a), the   health benefit plan issuer or pharmacy benefit manager may consider   the proposed modification or addendum approved by the pharmacist or   pharmacy and the modification or addendum takes effect on the date   described by Subsection (a).           (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 described by Section   1369.6025.   All financial terms, including reimbursement rates and   methodology, must be set forth in the contract.           (d)  This section does not apply to:                 (1)  a pharmacy benefit network contract:                       (A)  with an unspecified and indefinite duration;                       (B)     with no stated or automatic renewal period or   event; and                       (C)     that may only be terminated by notice from   one party to the other; or                 (2)     a proposed modification or addendum to a pharmacy   benefit network contract that is required by state or federal law or   rule.           Sec.   1369.6024.     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.   1369.6025.     PROVIDER MANUAL DISCLOSURE. A health   benefit plan issuer or pharmacy benefit manager shall:                 (1)     make a provider manual readily available on the   online portal described by Section 1369.6021; and                 (2)     post a modification or addendum to the provider   manual to the online portal in the same manner as a contract   modification or addendum under Section 1369.6023(a).           Sec.   1369.6026.     PHARMACY BENEFIT NETWORK CONTRACT FEE   LIMITATIONS.   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 contrac [Text truncated for display. Full text available on Congress.gov.]