Senate Bill 14 amends the Pharmacy Benefit Manager Regulation Act as follows: Section 3 amends the appeals process by requiring a PBM to reimburse a pharmacy in an amount that is calculated on a per-unit basis using the same generic product identifier or the generic code number.
Section 4 amends the existing provisions on PBM contracts so as to prohibit a PBM from requiring an insured to use a specific pharmacy if the PBM or its corporate affiliate has an ownership interest in the pharmacy, and also prohibits a PBM from charging a different costsharing amount for drugs or services at a non-affiliated pharmacy. Other provisions prohibit a PBM from requiring or incentivizing the purchase of a medication in a quantity greater than that prescribed, and prohibits denial or reduction of a claim unless the claim was intentionally submitted fraudulently, the claim was a duplicate of claim previously paid, or the goods or services were not properly rendered by the pharmacy or pharmacist.
Section 7 creates a new section of the PBM Regulation Act entitled “Pharmacy Benefits Reimbursement Transparency” authorizing the Superintendent to review and approve the compensation program of a PBM to ensure that the reimbursement for pharmacist services is fair. In addition, PBMs are required to report to the Superintendent information that is based on the PBM requirements adopted by the Texas legislature in 2021. The provisions also prohibit a PBM from being paid on a percentage of the cost of a drug, and requires payment based on a fixed fee determined in advance.
Section 9 creates a new section of the act entitled “Patient Cost Sharing” which prohibits a PBM from requiring an insured to make a payment for a covered prescription drug in an amount greater than (1) the applicable cost-sharing amount for the drug, (2) the amount an insured would pay if the insured purchased the drug without using a health benefits plan, (3) the total amount the pharmacy would be reimbursed for the drug from the PBM, or (4) the value of the rebate from a drug manufacturer provided to the PBM for the drug. When calculating an insured’s cost sharing obligation for covered drugs, an insurer must credit the insured for the out-of-pocket cost for the full value of any discounts provided or made by third parties at the time of the drug claim. The new provisions further provide that any rebate amount is to be counted toward the insured’s out-of-pocket prescription drug costs. Section 9 also provides that “if an insured or the insured’s health care provider identifies a clinically appropriate, non-formulary, specialty prescription drug available at a lower cost than a drug covered on the PBM’s formulary, the PBM must reimburse the insured, minus applicable cost sharing, for the non-formulary drug.” Section 10 requires a PBM to develop a drug formulary that covers “all medically necessary drugs.” Section 11 amends the act to include a provision that prohibits a PBM from restricting participation of a pharmacy in a pharmacy network if the pharmacy meets accreditation or certification requirements.