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A BILL TO BE ENTITLED
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AN ACT
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relating to the authority and rights of pharmacy services |
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administrative organizations to conduct the business of |
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independent pharmacies with respect to certain pharmacy benefits. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subchapter I, Chapter 843, Insurance Code, is |
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amended by adding Section 843.324 to read as follows: |
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Sec. 843.324. PHARMACY SERVICES ADMINISTRATIVE |
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ORGANIZATIONS. (a) In this section: |
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(1) "Independent pharmacy" means a pharmacy that is |
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under common ownership with not more than two other pharmacies. |
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(2) "Pharmacy benefit manager" means a person, other |
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than a pharmacist, pharmacy, or pharmacy services administrative |
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organization, who acts as an administrator in connection with |
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pharmacy benefits. |
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(3) "Pharmacy services administrative organization" |
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means an entity that contracts with an independent pharmacy to |
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conduct on behalf of the pharmacy the pharmacy's business with a |
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third-party payor, including a pharmacy benefit manager, in |
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connection with pharmacy benefits and to assist the pharmacy by |
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providing administrative services, including negotiating, |
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executing, and administering a contract with a third-party payor |
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and communicating with the third-party payor in connection with a |
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contract or pharmacy benefits. |
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(b) This section applies to a Medicaid managed care program |
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and a managed care organization that contracts with the Health and |
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Human Services Commission to provide services under Chapter 533, |
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Government Code. |
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(c) This section does not apply with respect to pharmacy |
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benefits under a self-insured, self-funded, or other employee |
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welfare benefit plan that is exempt from state regulation under the |
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Employee Retirement Income Security Act of 1974 (29 U.S.C. Section |
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1001 et seq.). |
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(d) Subject to Subsection (e), a pharmacy services |
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administrative organization designated and authorized by an |
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independent pharmacy as the pharmacy's agent and vested with actual |
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authority may conduct the pharmacy's business with a pharmacy |
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benefit manager in connection with pharmacy benefits provided under |
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a health maintenance organization plan and administered by a |
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pharmacy benefit manager. |
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(e) Before a pharmacy services administrative organization |
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may act on behalf of the independent pharmacy as described by |
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Subsection (d), the pharmacy must provide written notice to the |
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pharmacy benefit manager that the organization has the authority to |
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conduct the pharmacy's business with the pharmacy benefit manager |
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to the extent provided in the notice. The notice must detail the |
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specific nature and scope of the authority granted to the |
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organization with respect to the pharmacy's business with the |
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pharmacy benefit manager. |
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(f) A pharmacy benefit manager that receives a notice under |
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Subsection (e) shall recognize the authority of the pharmacy |
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services administrative organization to conduct the pharmacy's |
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business with the pharmacy benefit manager to the extent provided |
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in the notice. A pharmacy benefit manager may not refuse to deal |
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with the organization to the extent of the authority detailed in the |
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notice, including by refusing to: |
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(1) enter into a contract with the organization acting |
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on behalf of the independent pharmacy on terms agreed to by the |
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pharmacy benefit manager and organization; or |
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(2) communicate with the organization about any matter |
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relevant to the pharmacy or pharmacy benefits, including contract |
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provisions, maximum allowable cost lists, and reimbursement price |
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appeals. |
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(g) A pharmacy benefit manager may not require an |
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independent pharmacy acting through a pharmacy services |
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administrative organization under this section to participate as a |
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network provider or preferred provider under a particular health |
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benefit plan as a condition of participating as a network provider |
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or preferred provider under another health benefit plan. |
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(h) A pharmacy services administrative organization has the |
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same rights and obligations under this chapter as the independent |
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pharmacy on behalf of which the organization acts with respect to |
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pharmacy benefits provided under a health maintenance organization |
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plan and administered by a pharmacy benefit manager, to the extent |
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of the organization's authority to act with respect to those |
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benefits. |
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SECTION 2. Subchapter B, Chapter 1301, Insurance Code, is |
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amended by adding Section 1301.070 to read as follows: |
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Sec. 1301.070. PHARMACY SERVICES ADMINISTRATIVE |
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ORGANIZATIONS. (a) In this section: |
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(1) "Independent pharmacy" means a pharmacy that is |
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|
under common ownership with not more than two other pharmacies. |
|
|
(2) "Pharmacy benefit manager" means a person, other |
|
|
than a pharmacist, pharmacy, or pharmacy services administrative |
|
|
organization, who acts as an administrator in connection with |
|
|
pharmacy benefits. |
|
|
(3) "Pharmacy services administrative organization" |
|
|
means an entity that contracts with an independent pharmacy to |
|
|
conduct on behalf of the pharmacy the pharmacy's business with a |
|
|
third-party payor, including a pharmacy benefit manager, in |
|
|
connection with pharmacy benefits and to assist the pharmacy by |
|
|
providing administrative services, including negotiating, |
|
|
executing, and administering a contract with a third-party payor |
|
|
and communicating with the third-party payor in connection with a |
|
|
contract or pharmacy benefits. |
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|
(b) Notwithstanding Section 1301.0041, this section applies |
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to a Medicaid managed care program and a managed care organization |
|
|
that contracts with the Health and Human Services Commission to |
|
|
provide services under Chapter 533, Government Code. |
|
|
(c) This section does not apply with respect to pharmacy |
|
|
benefits under a self-insured, self-funded, or other employee |
|
|
welfare benefit plan that is exempt from state regulation under the |
|
|
Employee Retirement Income Security Act of 1974 (29 U.S.C. Section |
|
|
1001 et seq.). |
|
|
(d) Subject to Subsection (e), a pharmacy services |
|
|
administrative organization designated and authorized by an |
|
|
independent pharmacy as the pharmacy's agent and vested with actual |
|
|
authority may conduct the pharmacy's business with a pharmacy |
|
|
benefit manager in connection with pharmacy benefits provided under |
|
|
a preferred provider benefit plan and administered by a pharmacy |
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|
benefit manager. |
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|
(e) Before a pharmacy services administrative organization |
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may act on behalf of the independent pharmacy as described by |
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|
Subsection (d), the pharmacy must provide written notice to the |
|
|
pharmacy benefit manager that the organization has the authority to |
|
|
conduct the pharmacy's business with the pharmacy benefit manager |
|
|
to the extent provided in the notice. The notice must detail the |
|
|
specific nature and scope of the authority granted to the |
|
|
organization with respect to the pharmacy's business with the |
|
|
pharmacy benefit manager. |
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|
(f) A pharmacy benefit manager that receives a notice under |
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|
Subsection (e) shall recognize the authority of the pharmacy |
|
|
services administrative organization to conduct the pharmacy's |
|
|
business with the pharmacy benefit manager to the extent provided |
|
|
in the notice. A pharmacy benefit manager may not refuse to deal |
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|
with the organization to the extent of the authority detailed in the |
|
|
notice, including by refusing to: |
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|
(1) enter into a contract with the organization acting |
|
|
on behalf of the independent pharmacy on terms agreed to by the |
|
|
pharmacy benefit manager and organization; or |
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|
(2) communicate with the organization about any matter |
|
|
relevant to the pharmacy or pharmacy benefits, including contract |
|
|
provisions, maximum allowable cost lists, and reimbursement price |
|
|
appeals. |
|
|
(g) A pharmacy benefit manager may not require an |
|
|
independent pharmacy acting through a pharmacy services |
|
|
administrative organization under this section to participate as a |
|
|
network provider or preferred provider under a particular health |
|
|
benefit plan as a condition of participating as a network provider |
|
|
or preferred provider under another health benefit plan. |
|
|
(h) A pharmacy services administrative organization has the |
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|
same rights and obligations under this chapter as the independent |
|
|
pharmacy on behalf of which the organization acts with respect to |
|
|
pharmacy benefits provided under a preferred provider benefit plan |
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|
and administered by a pharmacy benefit manager, to the extent of the |
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organization's authority to act with respect to those benefits. |
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SECTION 3. This Act applies only to benefits provided under |
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a health benefit plan that is delivered, issued for delivery, or |
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renewed on or after the effective date of this Act. Benefits |
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provided under a health benefit plan delivered, issued for |
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delivery, or renewed before the effective date of this Act are |
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governed by the law as it existed immediately before the effective |
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date of this Act, and that law is continued in effect for that |
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purpose. |
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SECTION 4. This Act takes effect September 1, 2015. |