Bill > HB2978

This bill adds a new subchapter to the Texas Insurance Code that establishes minimum reimbursement requirements for pharmacists and pharmacies when pharmacy benefit managers (PBMs) process prescription drug claims. The bill requires PBMs to reimburse pharmacists and pharmacies at least their actual cost for prescription drugs and devices, prohibiting reimbursement rates that are lower than what the pharmacy paid for the medication. PBMs must provide a separate professional dispensing fee that matches the Medicaid fee-for-service model and cannot include this fee in the drug cost calculation. The legislation creates a mandatory appeal process for pharmacists who believe they have been improperly reimbursed, allowing them to challenge reimbursement rates within seven days of receiving payment. If a pharmacist successfully appeals, the PBM must adjust the reimbursement, provide necessary drug identification information, and allow claim rebilling. Conversely, if the PBM prevails in an appeal, they must provide information about alternative wholesale sources for the medication. The new regulations will apply to health benefit plans delivered or renewed on or after January 1, 2026, and the act will take effect on September 1, 2025. The bill specifically excludes certain types of health plans, such as Medicaid, TRICARE, and workers' compensation plans, from these requirements.