89R6156 SCL-D     By: Harris H.B. No. 2978       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.