Tex. Insurance Code § 1369.6022 — TX Code / Code in / Chapter 1369 / Section 1369.6022
§ 1369.6022.
Status: in_force

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.