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

89(R) SB 1236 - Enrolled version - Bill Text

S.B. No. 1236

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 contract, including any

financial terms applicable to the contract and corresponding

pharmacy benefit network.

Sec.

1369.6027.

PHARMACY BENEFIT NETWORK PARTICIPATION

REQUIREMENTS PROHIBITED. A health benefit plan issuer or pharmacy

benefit manager may not:

(1)

require a pharmacist or pharmacy to participate in

a pharmacy benefit network;

(2)

condition a pharmacist's or pharmacy's

participation in a pharmacy benefit network on participation in any

other pharmacy benefit network; or

(3)

penalize a pharmacist or pharmacy for refusing to

participate in a pharmacy benefit network.

SECTION 5. Section 1369.605, Insurance Code, is amended to

read as follows:

Sec. 1369.605. NETWORK CONTRACT FEE SCHEDULE. A pharmacy

benefit network contract must
include
[
specify or reference
] a

[
separate
] fee schedule. [
Unless otherwise available in the

contract, the fee schedule must be provided electronically in an

easily accessible and complete spreadsheet format and, on request,

in writing to each contracted pharmacist and pharmacy.
] The fee

schedule must describe:

(1) specific services or procedures that the

pharmacist or pharmacy may deliver and the amount of the

corresponding payment;

(2) a methodology for calculating the amount of the

payment based on a published fee schedule; or

(3) any other reasonable manner that provides an

ascertainable amount for payment for services.

SECTION 6. Section 1369.259(d), Insurance Code, is

repealed.

SECTION 7. (a) Section 1369.153, Insurance Code, as

amended by this Act, applies only to a health benefit plan

delivered, issued for delivery, or renewed on or after January 1,

2026. A health benefit plan delivered, issued for delivery, or

renewed before January 1, 2026, is governed by the law as it existed

immediately before the effective date of this Act, and that law is

continued in effect for that purpose.

(b) Chapter 1369, Insurance Code, as amended by this Act,

applies only to a contract entered into or renewed on or after the

effective date of this Act. A contract entered into or renewed

before the effective date of this Act is governed by the law as it

existed immediately before the effective date of this Act, and that

law is continued in effect for that purpose.

SECTION 8. This Act takes effect September 1, 2025.

______________________________

______________________________

President of the Senate

Speaker of the House

I hereby certify that S.B. No. 1236 passed the Senate on

April 24, 2025, by the following vote: Yeas 31, Nays 0.

______________________________

Secretary of the Senate

I hereby certify that S.B. No. 1236 passed the House on

May 13, 2025, by the following vote: Yeas 140, Nays 0, two

present not voting.

______________________________

Chief Clerk of the House

Approved:

______________________________

Date

______________________________

Governor