GREEN SHEET REDIGEST
HB 436 2018 Regular Session Johnson
(KEYWORD, SUMMARY, AND DIGEST as amended by Senate committee
amendments)
INSURANCE/HEALTH: Provides relative to the regulation of pharmacy benefit
managers.
DIGEST
Proposed law prohibits a pharmacy benefit manager, insurer, or other entity that administers
prescription drug benefits programs in La. from prohibiting by contract a pharmacy or
pharmacist from informing a patient of all relevant options when acquiring his prescription
medication, including but not limited to the cost and clinical efficacy of a more affordable
alternative if one is available and the ability to pay cash if a cash price for the same drug is
less than an insurance copayment or deductible payment amount.
Proposed law updates the phrase "pharmacy benefits manager" to "pharmacy benefit
manager".
Proposed law requires a pharmacy benefit manager to reimburse a pharmacy or pharmacist
in this state an amount not less than the amount that the pharmacy benefit manager
reimburses an affiliate of the pharmacy benefit manager for providing the same services.
Proposed law requires a pharmacy benefit manager, for every drug for which the pharmacy
benefit manager establishes a maximum allowable cost to determine the drug product
reimbursement, to make available to all pharmacies both of the following:
(1)Information identifying the national drug pricing compendia or sources used to obtain
the drug price data.
(2)The comprehensive list of drugs subject to maximum allowable cost and the actual
maximum allowable cost by plan for each drug.
Present law requires a pharmacy benefit manager to perform certain actions after an appeal
relative to maximum allowable cost is upheld.
Proposed law requires the pharmacy benefit manager, if the appeal is granted, to take the
following actions:
(1)Make the change in the Maximum Allowable Cost List to the initial date of service
the appealed drug was dispensed.
(2)Permit the appealing pharmacy and all other pharmacies in the network that filled
prescriptions for patients covered under the same health benefit plan to reverse and
resubmit claims and receive payment based on the adjusted maximum allowable cost
from the initial date of service the appealed drug was dispensed.
(3)Make the change effective for each similarly situated pharmacy as defined by the
payor subject to the Maximum Allowable Cost List and individually notify all
pharmacies in the pharmacy benefit manager's network.
(4)Make retroactive price adjustments in the next payment cycle.
Proposed law requires the pharmacy benefit manager to provide the commissioner, upon
request, information that is needed to resolve a complaint. Provides if the commissioner is
unable to obtain information from the pharmacy benefit manager that is necessary to resolve
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Prepared by Cheryl Cooper. the complaint, the reimbursement amount requested in the pharmacist's appeal shall be
granted.
Proposed law authorizes a pharmacist or pharmacy to file a complaint with the commissioner
of insurance following a final decision of the pharmacy benefit manager and provides for the
investigation of the complaint.
Proposed law applies only to pharmacies with fewer than 10 retail outlets physically located
within the state that are under a common corporate umbrella.
Proposed law requires information specifically designated as proprietary by the pharmacy
benefit manager to be given confidential treatment pursuant to present law.
Proposed law authorizes the commissioner to impose a reasonable fee upon pharmacy benefit
managers, in addition to a license fee and annual report fee, in order to cover the costs of
implementation and enforcement of present law and proposed law.
Proposed law permits the commissioner to promulgate rules and regulations in accordance
with the Administrative Procedure Act that are necessary or proper to carry out the
provisions of proposed law.
Proposed law allows any pharmacy benefit manager, insurer, or other entity that administers
prescription drug benefits programs that is aggrieved by an act of the commissioner to apply
for a hearing pursuant to present law.
Effective Jan. 1, 2019.
(Amends R.S. 22:1060.6(B), 1863(intro. para.), (1) and (6), 1864(A)(intro. para.) and (3) and
(B)(intro. para.) and 1865; Adds R.S. 22:1060.6(C), 1860.3, 1863(8),1864(A)(4), and 1866)
Summary of Amendments Adopted by House
The Committee Amendments Proposed by House Committee on Insurance to the original
bill:
1. Deletes proposed law requiring an appeal to be granted to the appealing
pharmacy if the commissioner is unable to obtain information from the pharmacy
benefit manager that is necessary to resolve the appeal.
2. Makes technical changes.
The House Floor Amendments to the engrossed bill:
1. Requires a reimbursement to a nonaffiliated pharmacy to be not less than the
reimbursement to an affiliated pharmacy for the same service.
2. Clarifies that proposed law applies to an insured individual.
3. Specifies that a pharmacist may disclose the insured's cost share of the
prescription.
4. Defines "drug shortage list".
5. Requires the list of the actual maximum allowable cost for each drug to be
organized by health plan.
6. Extends the time period for an appeal of a maximum allowable cost from 7
business days to 15 business days.
7. Extends the time period for responding to an appeal from 7 business days to 15
business days.
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Prepared by Cheryl Cooper. 8. Clarifies that a complaint may be filed with the commissioner after an appeal is
denied.
9. Changes the time for filing a complaint from 30 calendar days to 15 business
days.
10.Requires the complaint investigation to find that a decision was not in
compliance with the law prior to granting reimbursement to a pharmacy.
11.Requires the fee to be reasonable and adopted in accordance with the APA.
12.Makes technical changes.
Summary of Amendments Adopted by Senate
Committee Amendments Proposed by Senate Committee on Insurance to the reengrossed
bill
1. Prohibits an entity that administers prescription drug benefits programs from
prohibiting by contract a pharmacy or pharmacist from informing a patient of all
relevant options including the cost and clinical efficacy of a more affordable
alternative if one is available and the ability to pay cash if a cash price for the
same drug is less than an insurance copayment or deductible payment amount.
2. Requires the commissioner to grant the reimbursement amount requested in the
pharmacist's appeal if the commissioner is unable to obtain information from the
pharmacy benefit manager that is necessary to resolve a complaint.
3. Restricts application of proposed law to pharmacies with fewer than 10 retail
outlets physically located within the state under a common corporate umbrella.
4. Requires information designated as proprietary by the pharmacy benefit manager
to be given confidential treatment.
5. Permits the commissioner to promulgate rules and regulations in accordance with
the Administrative Procedure Act that are necessary or proper to carry out the
provisions of proposed law.
6. Permits an entity that administers prescription drug benefits programs to apply
for an administrative hearing pursuant to present law.
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Prepared by Cheryl Cooper.