Bill > SB1354

This bill establishes new regulations for pharmacy benefit managers (PBMs) regarding prescription drug and device reimbursements to network pharmacists and pharmacies in Texas. The legislation requires PBMs to reimburse pharmacies at least their actual cost for prescription drugs and devices, prohibiting reimbursement rates that are lower than what the pharmacy paid. The bill mandates that PBMs cannot include professional dispensing fees in calculating the reimbursement amount and must pay a dispensing fee at least equal to the Medicaid fee-for-service model rate. Additionally, the bill creates a formal appeal process for pharmacies to challenge reimbursement rates, allowing them to designate an agent to file appeals. If a pharmacy successfully appeals, the PBM must adjust the reimbursement, provide necessary drug code information, allow claim rebilling, and apply the appeal findings to similarly situated pharmacies. Conversely, if a PBM prevails in an appeal, they must provide information about wholesalers with comparable drug pricing. The law will apply to health benefit plans delivered or renewed on or after January 1, 2026, and will take effect on September 1, 2025. Notably, the bill does not apply to certain government health programs like Medicaid, TRICARE, and workers' compensation plans.