1 | 1 | | |
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2 | 2 | | Introduced Version |
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3 | 3 | | HOUSE BILL No. 1606 |
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4 | 4 | | _____ |
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5 | 5 | | DIGEST OF INTRODUCED BILL |
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6 | 6 | | Citations Affected: IC 27-1-24.5; IC 27-1-44.5-12; IC 27-1-48.5. |
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7 | 7 | | Synopsis: Pharmacy benefit managers. Prohibits a pharmacy benefit |
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8 | 8 | | manager from taking certain actions. Requires a pharmacy benefit |
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9 | 9 | | manager to submit a report to the insurance commissioner every six |
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10 | 10 | | months. (Current law requires a pharmacy benefit manager to submit |
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11 | 11 | | the report annually.) Provides that if a contract holder requests an audit |
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12 | 12 | | of compliance with the contract from a pharmacy benefit manager, the |
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13 | 13 | | pharmacy benefit manager must provide the audit requested to the |
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14 | 14 | | contract holder not later than 30 business days after receiving the |
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15 | 15 | | request. Removes the provision specifying that the files or forms |
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16 | 16 | | disclosed to the contract holder by the pharmacy benefit manager as |
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17 | 17 | | part of an audit of compliance with the contract may be modified to |
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18 | 18 | | redact trade secrets. Establishes civil penalties that the department of |
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19 | 19 | | insurance (department) shall impose for a violation of the provisions |
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20 | 20 | | concerning pharmacy benefit managers. Requires a pharmacy benefit |
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21 | 21 | | manager to provide additional information in the pharmacy benefit |
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22 | 22 | | manager's report to the department. Requires, after June 30, 2025, a |
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23 | 23 | | health payer to include information relating to prescription drug pricing |
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24 | 24 | | in the data submitted to the all payer claims data base by the health |
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25 | 25 | | payer. Requires a health plan to credit toward a covered individual's |
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26 | 26 | | deductible and annual maximum out-of-pocket expenses any amount |
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27 | 27 | | the covered individual pays directly to any health care provider for a |
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28 | 28 | | medically necessary covered health care service if a claim for the |
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29 | 29 | | health care service is not submitted to the health plan and the amount |
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30 | 30 | | paid by the covered individual to the health care provider is less than |
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31 | 31 | | the average discounted rate for the health care service paid to a health |
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32 | 32 | | care provider in the health plan's network. |
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33 | 33 | | Effective: July 1, 2025; January 1, 2026. |
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34 | 34 | | McGuire, Barrett, King, Isa |
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35 | 35 | | January 21, 2025, read first time and referred to Committee on Insurance. |
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36 | 36 | | 2025 IN 1606—LS 7630/DI 141 Introduced |
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37 | 37 | | First Regular Session of the 124th General Assembly (2025) |
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38 | 38 | | PRINTING CODE. Amendments: Whenever an existing statute (or a section of the Indiana |
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39 | 39 | | Constitution) is being amended, the text of the existing provision will appear in this style type, |
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40 | 40 | | additions will appear in this style type, and deletions will appear in this style type. |
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41 | 41 | | Additions: Whenever a new statutory provision is being enacted (or a new constitutional |
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42 | 42 | | provision adopted), the text of the new provision will appear in this style type. Also, the |
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43 | 43 | | word NEW will appear in that style type in the introductory clause of each SECTION that adds |
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44 | 44 | | a new provision to the Indiana Code or the Indiana Constitution. |
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45 | 45 | | Conflict reconciliation: Text in a statute in this style type or this style type reconciles conflicts |
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46 | 46 | | between statutes enacted by the 2024 Regular Session of the General Assembly. |
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47 | 47 | | HOUSE BILL No. 1606 |
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48 | 48 | | A BILL FOR AN ACT to amend the Indiana Code concerning |
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49 | 49 | | insurance. |
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50 | 50 | | Be it enacted by the General Assembly of the State of Indiana: |
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51 | 51 | | 1 SECTION 1. IC 27-1-24.5-16.5 IS ADDED TO THE INDIANA |
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52 | 52 | | 2 CODE AS A NEW SECTION TO READ AS FOLLOWS |
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53 | 53 | | 3 [EFFECTIVE JULY 1, 2025]: Sec. 16.5. As used in this chapter, |
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54 | 54 | | 4 "spread pricing" means the practice in which a pharmacy benefit |
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55 | 55 | | 5 manager charges a health plan a different amount for pharmacist |
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56 | 56 | | 6 services than the amount the pharmacy benefit manager |
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57 | 57 | | 7 reimburses a pharmacy for the pharmacist services. |
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58 | 58 | | 8 SECTION 2. IC 27-1-24.5-19, AS AMENDED BY P.L.196-2021, |
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59 | 59 | | 9 SECTION 22, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE |
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60 | 60 | | 10 JULY 1, 2025]: Sec. 19. (a) A pharmacy benefit manager shall provide |
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61 | 61 | | 11 equal access and incentives to all pharmacies within the pharmacy |
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62 | 62 | | 12 benefit manager's network. |
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63 | 63 | | 13 (b) A pharmacy benefit manager may not do any of the following: |
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64 | 64 | | 14 (1) Condition participation in any network on accreditation, |
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65 | 65 | | 15 credentialing, or licensing of a pharmacy, other than a license or |
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66 | 66 | | 16 permit required by the Indiana board of pharmacy or other state |
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67 | 67 | | 17 or federal regulatory authority for the services provided by the |
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68 | 68 | | 2025 IN 1606—LS 7630/DI 141 2 |
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69 | 69 | | 1 pharmacy. However, nothing in this subdivision precludes the |
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70 | 70 | | 2 department from providing credentialing or accreditation |
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71 | 71 | | 3 standards for pharmacies. |
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72 | 72 | | 4 (2) Discriminate against any pharmacy. |
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73 | 73 | | 5 (3) Directly or indirectly retroactively deny a claim or aggregate |
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74 | 74 | | 6 of claims after the claim or aggregate of claims has been |
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75 | 75 | | 7 adjudicated, unless any of the following apply: |
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76 | 76 | | 8 (A) The original claim was submitted fraudulently. |
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77 | 77 | | 9 (B) The original claim payment was incorrect because the |
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78 | 78 | | 10 pharmacy or pharmacist had already been paid for the drug. |
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79 | 79 | | 11 (C) The pharmacist services were not properly rendered by the |
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80 | 80 | | 12 pharmacy or pharmacist. |
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81 | 81 | | 13 (4) Reduce, directly or indirectly, payment to a pharmacy for |
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82 | 82 | | 14 pharmacist services to an effective rate of reimbursement, |
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83 | 83 | | 15 including permitting an insurer or plan sponsor to make such a |
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84 | 84 | | 16 reduction. |
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85 | 85 | | 17 (5) Reimburse a pharmacy that is affiliated with the pharmacy |
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86 | 86 | | 18 benefit manager, other than solely being included in the pharmacy |
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87 | 87 | | 19 benefit manager's network, at a greater reimbursement rate than |
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88 | 88 | | 20 other pharmacies in the same network. |
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89 | 89 | | 21 (6) Impose limits, including quantity limits or refill frequency |
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90 | 90 | | 22 limits, on a pharmacy's access to medication that differ from those |
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91 | 91 | | 23 existing for a pharmacy benefit manager affiliate. |
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92 | 92 | | 24 (7) Share any covered individual's information including |
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93 | 93 | | 25 de-identified covered individual information, received from a |
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94 | 94 | | 26 pharmacy or pharmacy benefit manager affiliate, except as |
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95 | 95 | | 27 permitted by the federal Health Insurance Portability and |
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96 | 96 | | 28 Accountability Act (HIPAA) (P.L.104-191). |
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97 | 97 | | 29 (8) Require a covered individual, as a condition of payment or |
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98 | 98 | | 30 reimbursement, to purchase pharmacist services, including |
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99 | 99 | | 31 prescription drugs, exclusively through a pharmacy benefit |
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100 | 100 | | 32 manager affiliate. |
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101 | 101 | | 33 (9) Prohibit or limit any covered individual from selecting an |
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102 | 102 | | 34 in network pharmacy or pharmacist of the covered |
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103 | 103 | | 35 individual's choice that meets and agrees to the terms and |
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104 | 104 | | 36 conditions in the pharmacy benefit manager's contract. |
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105 | 105 | | 37 (10) Impose a monetary advantage or penalty under a health |
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106 | 106 | | 38 plan that would affect a covered individual's choice of |
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107 | 107 | | 39 pharmacy among the pharmacies that have chosen to contract |
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108 | 108 | | 40 with the pharmacy benefit manager, under the same terms |
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109 | 109 | | 41 and conditions described in subdivision (9). |
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110 | 110 | | 42 (11) Retroactively: |
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111 | 111 | | 2025 IN 1606—LS 7630/DI 141 3 |
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112 | 112 | | 1 (A) impose fees on a pharmacy; or |
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113 | 113 | | 2 (B) reduce the reimbursement amount for pharmacist |
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114 | 114 | | 3 services issued by the pharmacy. |
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115 | 115 | | 4 A violation of this subsection by a pharmacy benefit manager |
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116 | 116 | | 5 constitutes an unfair or deceptive act or practice in the business of |
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117 | 117 | | 6 insurance under IC 27-4-1-4. |
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118 | 118 | | 7 SECTION 3. IC 27-1-24.5-21, AS ADDED BY P.L.68-2020, |
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119 | 119 | | 8 SECTION 1, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE |
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120 | 120 | | 9 JULY 1, 2025]: Sec. 21. (a) Beginning June 1, 2021, and annually |
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121 | 121 | | 10 every six (6) months thereafter, a pharmacy benefit manager shall |
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122 | 122 | | 11 submit a report containing data from the immediately preceding |
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123 | 123 | | 12 calendar year six (6) months to the commissioner. The commissioner |
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124 | 124 | | 13 shall determine what must be included in the report and consider the |
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125 | 125 | | 14 following information to be included in the report: |
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126 | 126 | | 15 (1) The aggregate amount of all rebates that the pharmacy benefit |
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127 | 127 | | 16 manager received from all pharmaceutical manufacturers for: |
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128 | 128 | | 17 (A) all insurers; and |
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129 | 129 | | 18 (B) each insurer; |
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130 | 130 | | 19 with which the pharmacy benefit manager contracted during the |
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131 | 131 | | 20 immediately preceding calendar year. six (6) months. |
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132 | 132 | | 21 (2) The aggregate amount of administrative fees that the |
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133 | 133 | | 22 pharmacy benefit manager received from all pharmaceutical |
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134 | 134 | | 23 manufacturers for: |
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135 | 135 | | 24 (A) all insurers; and |
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136 | 136 | | 25 (B) each insurer; |
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137 | 137 | | 26 with which the pharmacy benefit manager contracted during the |
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138 | 138 | | 27 immediately preceding calendar year. six (6) months. |
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139 | 139 | | 28 (3) The aggregate amount of retained rebates that the pharmacy |
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140 | 140 | | 29 benefit manager received from all pharmaceutical manufacturers |
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141 | 141 | | 30 and did not pass through to insurers with which the pharmacy |
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142 | 142 | | 31 benefit manager contracted during the immediately preceding |
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143 | 143 | | 32 calendar year. six (6) months. |
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144 | 144 | | 33 (4) The highest, lowest, and mean aggregate retained rebate for: |
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145 | 145 | | 34 (A) all insurers; and |
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146 | 146 | | 35 (B) each insurer; |
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147 | 147 | | 36 with which the pharmacy benefit manager contracted during the |
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148 | 148 | | 37 immediately preceding calendar year. six (6) months. |
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149 | 149 | | 38 (b) Except as provided in section 29(b) of this chapter, a |
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150 | 150 | | 39 pharmacy benefit manager that provides information under this section |
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151 | 151 | | 40 may designate the information as a trade secret (as defined in |
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152 | 152 | | 41 IC 24-2-3-2). Information designated as a trade secret under this |
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153 | 153 | | 42 subsection must not be published unless required under subsection (c). |
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154 | 154 | | 2025 IN 1606—LS 7630/DI 141 4 |
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155 | 155 | | 1 (c) Except as provided in section 29(b) of this chapter, disclosure |
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156 | 156 | | 2 of information designated as a trade secret under subsection (b) may be |
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157 | 157 | | 3 ordered by a court of Indiana for good cause shown or made in a court |
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158 | 158 | | 4 filing. |
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159 | 159 | | 5 SECTION 4. IC 27-1-24.5-25, AS AMENDED BY P.L.152-2024, |
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160 | 160 | | 6 SECTION 12, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE |
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161 | 161 | | 7 JULY 1, 2025]: Sec. 25. (a) A contract holder may, one (1) time in a |
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162 | 162 | | 8 calendar year and not earlier than six (6) months following a previously |
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163 | 163 | | 9 requested audit, request an audit of compliance with the contract. If |
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164 | 164 | | 10 requested by the contract holder, the audit shall include full disclosure |
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165 | 165 | | 11 of the following data specific to the contract holder: |
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166 | 166 | | 12 (1) Rebate amounts secured on prescription drugs, whether |
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167 | 167 | | 13 product specific or general rebates, that were provided by a |
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168 | 168 | | 14 pharmaceutical manufacturer. The information provided under |
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169 | 169 | | 15 this subdivision must identify the prescription drugs by |
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170 | 170 | | 16 therapeutic category. |
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171 | 171 | | 17 (2) Pharmaceutical and device claims received by the pharmacy |
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172 | 172 | | 18 benefit manager on any of the following: |
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173 | 173 | | 19 (A) The CMS-1500 form or its successor form. |
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174 | 174 | | 20 (B) The HCFA-1500 form or its successor form. |
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175 | 175 | | 21 (C) The HIPAA X12 837P electronic claims transaction for |
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176 | 176 | | 22 professional services, or its successor transaction. |
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177 | 177 | | 23 (D) The HIPAA X12 837I institutional form or its successor |
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178 | 178 | | 24 form. |
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179 | 179 | | 25 (E) The CMS-1450 form or its successor form. |
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180 | 180 | | 26 (F) The UB-04 form or its successor form. |
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181 | 181 | | 27 The forms or transaction may be modified as necessary to comply |
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182 | 182 | | 28 with the federal Health Insurance Portability and Accountability |
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183 | 183 | | 29 Act (HIPAA) (P.L. 104-191). or to redact a trade secret (as |
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184 | 184 | | 30 defined in IC 24-2-3-2). |
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185 | 185 | | 31 (3) Pharmaceutical and device claims payments or electronic |
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186 | 186 | | 32 funds transfer or remittance advice notices provided by the |
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187 | 187 | | 33 pharmacy benefit manager as ASC X12N 835 files or a successor |
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188 | 188 | | 34 format. The files may be modified as necessary to comply with |
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189 | 189 | | 35 the federal Health Insurance Portability and Accountability Act |
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190 | 190 | | 36 (HIPAA) (P.L. 104-191). or to redact a trade secret (as defined in |
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191 | 191 | | 37 IC 24-2-3-2). In the event that paper claims are provided, the |
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192 | 192 | | 38 pharmacy benefit manager shall convert the paper claims to the |
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193 | 193 | | 39 ASC X12N 835 electronic format or a successor format. |
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194 | 194 | | 40 (4) Any other revenue and fees derived by the pharmacy benefit |
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195 | 195 | | 41 manager from the contract, including all direct and indirect |
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196 | 196 | | 42 remuneration from pharmaceutical manufacturers regardless of |
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197 | 197 | | 2025 IN 1606—LS 7630/DI 141 5 |
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198 | 198 | | 1 whether the remuneration is classified as a rebate, fee, or another |
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199 | 199 | | 2 term. |
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200 | 200 | | 3 (b) A pharmacy benefit manager may not impose the following: |
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201 | 201 | | 4 (1) Fees for: |
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202 | 202 | | 5 (A) requesting an audit under this section; or |
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203 | 203 | | 6 (B) selecting an auditor other than an auditor designated by the |
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204 | 204 | | 7 pharmacy benefit manager. |
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205 | 205 | | 8 (2) Conditions that would restrict a contract holder's right to |
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206 | 206 | | 9 conduct an audit under this section, including restrictions on the: |
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207 | 207 | | 10 (A) time period of the audit; |
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208 | 208 | | 11 (B) number of claims analyzed; |
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209 | 209 | | 12 (C) type of analysis conducted; |
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210 | 210 | | 13 (D) data elements used in the analysis; or |
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211 | 211 | | 14 (E) selection of an auditor as long as the auditor: |
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212 | 212 | | 15 (i) does not have a conflict of interest; |
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213 | 213 | | 16 (ii) meets a threshold for liability insurance specified in the |
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214 | 214 | | 17 contract between the parties; |
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215 | 215 | | 18 (iii) does not work on a contingent fee basis; and |
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216 | 216 | | 19 (iv) does not have a history of breaching nondisclosure |
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217 | 217 | | 20 agreements. |
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218 | 218 | | 21 (c) A pharmacy benefit manager shall disclose, upon request from |
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219 | 219 | | 22 a contract holder, to the contract holder the actual amounts directly or |
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220 | 220 | | 23 indirectly paid by the pharmacy benefit manager to the pharmacist or |
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221 | 221 | | 24 pharmacy for the drug and for pharmacist services related to the drug. |
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222 | 222 | | 25 (d) A pharmacy benefit manager shall provide notice to a contract |
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223 | 223 | | 26 holder contracting with the pharmacy benefit manager of any |
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224 | 224 | | 27 consideration, including direct or indirect remuneration, that the |
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225 | 225 | | 28 pharmacy benefit manager receives from a pharmaceutical |
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226 | 226 | | 29 manufacturer or group purchasing organization for formulary |
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227 | 227 | | 30 placement or any other reason. |
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228 | 228 | | 31 (e) The commissioner may establish a procedure to release |
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229 | 229 | | 32 information from an audit performed by the department to a contract |
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230 | 230 | | 33 holder that has requested an audit under this section in a manner that |
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231 | 231 | | 34 does not violate confidential or proprietary information laws. |
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232 | 232 | | 35 (f) A contract that is entered into, issued, amended, or renewed after |
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233 | 233 | | 36 June 30, 2024, may not contain a provision that violates this section. |
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234 | 234 | | 37 (g) A pharmacy benefit manager shall: |
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235 | 235 | | 38 (1) obtain any information requested in an audit under this section |
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236 | 236 | | 39 from a group purchasing organization or other partner entity of |
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237 | 237 | | 40 the pharmacy benefit manager; and |
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238 | 238 | | 41 (2) confirm receipt of a request for an audit under this section to |
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239 | 239 | | 42 the contract holder not later than ten (10) business days after the |
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240 | 240 | | 2025 IN 1606—LS 7630/DI 141 6 |
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241 | 241 | | 1 information is requested; and |
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242 | 242 | | 2 (3) provide the audit requested under this section to the |
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243 | 243 | | 3 contract holder not later than thirty (30) business days after |
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244 | 244 | | 4 receiving the request. |
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245 | 245 | | 5 (h) Information provided in an audit under this section must be |
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246 | 246 | | 6 provided in accordance with the federal Health Insurance Portability |
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247 | 247 | | 7 and Accountability Act (HIPAA) (P.L. 104-191). |
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248 | 248 | | 8 SECTION 5. IC 27-1-24.5-27.7 IS ADDED TO THE INDIANA |
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249 | 249 | | 9 CODE AS A NEW SECTION TO READ AS FOLLOWS |
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250 | 250 | | 10 [EFFECTIVE JULY 1, 2025]: Sec. 27.7. A pharmacy benefit |
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251 | 251 | | 11 manager may not engage in spread pricing. |
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252 | 252 | | 12 SECTION 6. IC 27-1-24.5-28, AS ADDED BY P.L.68-2020, |
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253 | 253 | | 13 SECTION 1, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE |
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254 | 254 | | 14 JANUARY 1, 2026]: Sec. 28. (a) A violation of this chapter is an |
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255 | 255 | | 15 unfair or deceptive act or practice in the business of insurance under |
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256 | 256 | | 16 IC 27-4-1-4. |
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257 | 257 | | 17 (b) The department may also adopt rules under IC 4-22-2 to set forth |
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258 | 258 | | 18 fines for a violation under this chapter. |
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259 | 259 | | 19 (b) Except as provided in subsections (c) and (d), the |
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260 | 260 | | 20 department shall impose a civil penalty for a violation of this |
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261 | 261 | | 21 chapter, in the following amounts: |
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262 | 262 | | 22 (1) One thousand dollars ($1,000) for the first violation. |
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263 | 263 | | 23 (2) Five thousand dollars ($5,000) for the second violation. |
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264 | 264 | | 24 (3) Ten thousand dollars ($10,000) for each additional |
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265 | 265 | | 25 violation. |
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266 | 266 | | 26 (c) If a pharmacy benefit manager has been assessed a civil |
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267 | 267 | | 27 penalty under subsection (b) for a violation of this chapter, the |
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268 | 268 | | 28 pharmacy benefit manager shall have thirty (30) calendar days to |
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269 | 269 | | 29 correct the violation before the pharmacy benefit manager may be |
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270 | 270 | | 30 assessed another civil penalty under subsection (b). |
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271 | 271 | | 31 (d) If a pharmacy benefit manager has been assessed a civil |
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272 | 272 | | 32 penalty under subsection (b) for a violation of this chapter that |
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273 | 273 | | 33 resulted from a clerical error or unintentional omission on the part |
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274 | 274 | | 34 of the pharmacy benefit manager, the department shall not |
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275 | 275 | | 35 escalate the civil penalty imposed on the pharmacy benefit |
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276 | 276 | | 36 manager under subsection (b). |
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277 | 277 | | 37 (e) If a pharmacy benefit manager has been assessed multiple |
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278 | 278 | | 38 civil penalties for violations of this chapter, the department may |
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279 | 279 | | 39 revoke the pharmacy benefit manager's license issued by the |
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280 | 280 | | 40 commissioner under section 18 of this chapter. |
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281 | 281 | | 41 SECTION 7. IC 27-1-24.5-29, AS ADDED BY P.L.166-2023, |
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282 | 282 | | 42 SECTION 1, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE |
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283 | 283 | | 2025 IN 1606—LS 7630/DI 141 7 |
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284 | 284 | | 1 JULY 1, 2025]: Sec. 29. (a) At least every six (6) months, a pharmacy |
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285 | 285 | | 2 benefit manager shall provide a report to the department. |
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286 | 286 | | 3 (b) A report under subsection (a) must include the following |
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287 | 287 | | 4 information: |
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288 | 288 | | 5 (1) The overall aggregate amount charged to a health plan for all |
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289 | 289 | | 6 pharmaceutical claims processed by the pharmacy benefit |
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290 | 290 | | 7 manager for the immediately preceding six (6) months. and |
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291 | 291 | | 8 (2) The overall aggregate amount paid to pharmacies for claims |
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292 | 292 | | 9 processed by the pharmacy benefit manager for the immediately |
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293 | 293 | | 10 preceding six (6) months. |
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294 | 294 | | 11 (3) The overall aggregate amount of all rebates that the |
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295 | 295 | | 12 pharmacy benefit manager received from all pharmaceutical |
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296 | 296 | | 13 manufacturers for: |
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297 | 297 | | 14 (A) all insurers; and |
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298 | 298 | | 15 (B) each insurer; |
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299 | 299 | | 16 with which the pharmacy benefit manager contracted during |
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300 | 300 | | 17 the immediately preceding six (6) months. |
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301 | 301 | | 18 (4) The overall aggregate amount of administrative fees that |
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302 | 302 | | 19 the pharmacy benefit manager received from all |
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303 | 303 | | 20 pharmaceutical manufacturers for: |
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304 | 304 | | 21 (A) all insurers; and |
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305 | 305 | | 22 (B) each insurer; |
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306 | 306 | | 23 with which the pharmacy benefit manager contracted during |
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307 | 307 | | 24 the immediately preceding six (6) months. |
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308 | 308 | | 25 (5) The overall aggregate amount of retained rebates that the |
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309 | 309 | | 26 pharmacy benefit manager received from all pharmaceutical |
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310 | 310 | | 27 manufacturers and did not pass through to insurers with |
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311 | 311 | | 28 which the pharmacy benefit manager contracted during the |
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312 | 312 | | 29 immediately preceding six (6) months. |
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313 | 313 | | 30 (c) Upon request, the department shall make a report received under |
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314 | 314 | | 31 subsection (a) available to the members of the general assembly in an |
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315 | 315 | | 32 electronic format under IC 5-14-6. |
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316 | 316 | | 33 SECTION 8. IC 27-1-44.5-12 IS ADDED TO THE INDIANA |
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317 | 317 | | 34 CODE AS A NEW SECTION TO READ AS FOLLOWS |
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318 | 318 | | 35 [EFFECTIVE JULY 1, 2025]: Sec. 12. After June 30, 2025, a health |
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319 | 319 | | 36 payer shall include in the data submitted to the data base under |
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320 | 320 | | 37 this chapter the following pricing information relating to a |
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321 | 321 | | 38 prescription drug covered by the health payer: |
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322 | 322 | | 39 (1) The wholesale price. |
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323 | 323 | | 40 (2) The retail price. |
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324 | 324 | | 41 (3) The negotiated price. |
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325 | 325 | | 42 SECTION 9. IC 27-1-48.5 IS ADDED TO THE INDIANA CODE |
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326 | 326 | | 2025 IN 1606—LS 7630/DI 141 8 |
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327 | 327 | | 1 AS A NEW CHAPTER TO READ AS FOLLOWS [EFFECTIVE |
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328 | 328 | | 2 JULY 1, 2025]: |
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329 | 329 | | 3 Chapter 48.5. Out-of-Pocket Expense Credit |
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330 | 330 | | 4 Sec. 1. This chapter applies to a health plan entered into or |
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331 | 331 | | 5 renewed after June 30, 2025. |
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332 | 332 | | 6 Sec. 2. As used in this chapter, "covered individual" means an |
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333 | 333 | | 7 individual entitled to coverage under a health plan. |
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334 | 334 | | 8 Sec. 3. As used in this chapter, "health care provider" means an |
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335 | 335 | | 9 individual or entity that is licensed, certified, registered, or |
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336 | 336 | | 10 regulated by an entity described in IC 25-0.5-11. |
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337 | 337 | | 11 Sec. 4. (a) As used in this chapter, "health care services" means |
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338 | 338 | | 12 any services or products rendered by a health care provider within |
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339 | 339 | | 13 the scope of the provider's license or legal authorization. |
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340 | 340 | | 14 (b) The term includes hospital, medical, surgical, and |
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341 | 341 | | 15 pharmaceutical services or products. |
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342 | 342 | | 16 Sec. 5. (a) As used in this chapter, "health plan" means any of |
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343 | 343 | | 17 the following: |
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344 | 344 | | 18 (1) A self-insurance program established under IC 5-10-8-7(b) |
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345 | 345 | | 19 to provide group coverage. |
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346 | 346 | | 20 (2) A prepaid health care delivery plan through which health |
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347 | 347 | | 21 services are provided under IC 5-10-8-7(c). |
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348 | 348 | | 22 (3) A policy of accident and sickness insurance as defined in |
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349 | 349 | | 23 IC 27-8-5-1, but not including any insurance, plan, or policy |
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350 | 350 | | 24 set forth in IC 27-8-5-2.5(a). |
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351 | 351 | | 25 (4) An individual contract (as defined in IC 27-13-1-21) or a |
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352 | 352 | | 26 group contract (as defined in IC 27-13-1-16) with a health |
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353 | 353 | | 27 maintenance organization that provides coverage for basic |
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354 | 354 | | 28 health care services (as defined in IC 27-13-1-4). |
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355 | 355 | | 29 (5) A self-funded health benefit plan that complies with the |
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356 | 356 | | 30 federal Employee Retirement Income Security Act (ERISA) |
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357 | 357 | | 31 of 1974 (29 U.S.C. 1001 et seq.). |
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358 | 358 | | 32 (b) The term includes a person that administers any of the |
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359 | 359 | | 33 following: |
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360 | 360 | | 34 (1) A self-insurance program established under IC 5-10-8-7(b) |
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361 | 361 | | 35 to provide group coverage. |
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362 | 362 | | 36 (2) A prepaid health care delivery plan through which health |
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363 | 363 | | 37 services are provided under IC 5-10-8-7(c). |
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364 | 364 | | 38 (3) A policy of accident and sickness insurance as defined in |
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365 | 365 | | 39 IC 27-8-5-1, but not including any insurance, plan, or policy |
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366 | 366 | | 40 set forth in IC 27-8-5-2.5(a). |
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367 | 367 | | 41 (4) An individual contract (as defined in IC 27-13-1-21) or a |
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368 | 368 | | 42 group contract (as defined in IC 27-13-1-16) with a health |
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369 | 369 | | 2025 IN 1606—LS 7630/DI 141 9 |
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370 | 370 | | 1 maintenance organization that provides coverage for basic |
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371 | 371 | | 2 health care services (as defined in IC 27-13-1-4). |
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372 | 372 | | 3 (5) A self-funded health benefit plan that complies with the |
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373 | 373 | | 4 federal Employee Retirement Income Security Act (ERISA) |
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374 | 374 | | 5 of 1974 (29 U.S.C. 1001 et seq.). |
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375 | 375 | | 6 Sec. 6. As used in this chapter, "network" means a group of |
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376 | 376 | | 7 health care providers that: |
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377 | 377 | | 8 (1) provide health care services to covered individuals; and |
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378 | 378 | | 9 (2) have agreed to, or are otherwise subject to, maximum |
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379 | 379 | | 10 limits on the prices for the health care services to be provided |
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380 | 380 | | 11 to the covered individuals. |
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381 | 381 | | 12 Sec. 7. A health plan shall credit toward a covered individual's |
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382 | 382 | | 13 deductible and annual maximum out-of-pocket expenses any |
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383 | 383 | | 14 amount the covered individual pays directly to any health care |
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384 | 384 | | 15 provider for a medically necessary covered health care service if a |
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385 | 385 | | 16 claim for the health care service is not submitted to the health plan |
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386 | 386 | | 17 and the amount paid by the covered individual to the health care |
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387 | 387 | | 18 provider is less than the average discounted rate for the health care |
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388 | 388 | | 19 service paid to a health care provider in the health plan's network. |
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389 | 389 | | 20 Sec. 8. A health plan shall: |
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390 | 390 | | 21 (1) establish a procedure by which a covered individual may |
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391 | 391 | | 22 claim a credit under section 7 of this chapter; and |
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392 | 392 | | 23 (2) identify documentation necessary to support a claim for a |
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393 | 393 | | 24 credit under section 7 of this chapter. |
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394 | 394 | | 25 Sec. 9. A health plan shall display information about the |
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395 | 395 | | 26 procedure and documentation described in section 8 of this chapter |
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396 | 396 | | 27 on its website. |
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397 | 397 | | 28 Sec. 10. The department shall adopt rules under IC 4-22-2 to |
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398 | 398 | | 29 effectuate the provisions of this chapter. |
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399 | 399 | | 30 SECTION 10. [EFFECTIVE JULY 1, 2025] (a) The Indiana |
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400 | 400 | | 31 department of insurance shall amend its administrative rules to |
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401 | 401 | | 32 conform with IC 27-1-24.5-28, as amended by this act. |
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402 | 402 | | 33 (b) The Indiana department of insurance shall begin the process |
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403 | 403 | | 34 of amending its administrative rules under subsection (a) not later |
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404 | 404 | | 35 than December 31, 2025. |
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405 | 405 | | 36 (c) This SECTION expires July 1, 2028. |
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406 | 406 | | 2025 IN 1606—LS 7630/DI 141 |
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