RÉSUMÉ DIGEST
ACT 50 (SB 191) 2021 Regular Session Cloud
New law prohibits a health insurance issuer, pharmacy benefit manager, or their agent from
refusing to authorize, approve, or pay a participating provider for providing covered
physician-administered drugs and related services to covered persons. Further prohibits a
health insurance issuer, pharmacy benefit manager, or their agent from conditioning,
denying, restricting, refusing to authorize or approve, or reducing payment to a participating
provider for a physician-administered drug when all criteria for medical necessity are met
because the participating provider obtains physician-administered drugs from a pharmacy
that is not a participating provider in the health insurance issuer's network. Requires that the
drug supplied meets the supply chain security controls and chain of distribution set forth by
the federal Drug Supply Chain Security Act.
Provides that "participating provider" includes any clinic, hospital outpatient department or
pharmacy under common ownership or control of the participating provider.
Requires payment to a participating provider to be at the rate set forth in the health insurance
issuer's agreement with the provider applicable to such drugs. If no rate is included in the
agreement, the payment shall be at the wholesale acquisition cost.
Prohibits a health insurance issuer, pharmacy benefit manager, or their agent from requiring
a covered person pay an additional fee, or any other increased cost-sharing amount in
addition to applicable cost-sharing amounts payable by the covered person as designated
within the benefit plan to obtain the physician-administered drug when provided by a
participating provider.
New law does not prohibit a health insurance issuer or its agent from establishing differing
copayments or other cost-sharing amounts within the benefit plan for covered persons who
acquire physician-administered drugs from other providers nor shall it prohibit a health
insurance issuer or its agent from refusing to authorize or approve or from denying coverage
of a physician-administered drug based upon failure to satisfy medical necessity criteria.
Provides that the location of receiving the physician-administered drug is not to be included
in the medical necessity criteria.
New law does not prohibit a health insurance issuer from establishing specialty care centers
of excellence based on nationally established, objective quality measures, to be utilized by
covered persons focused on specific drugs or types of drugs to impact the safety, quality,
affordability, and expertise of treatment.
Prohibits a pharmacy benefit manager or person acting on behalf of a pharmacy benefit
manager from conditioning, denying, restricting, refusing to authorize or approve, or
reducing payment to a pharmacy or pharmacist for providing covered
physician-administered drugs and related services to an enrollee. Reimbursement shall be
at the rate set forth in the contract between the pharmacy benefit manager or person acting
on behalf of a pharmacy benefit manager with the pharmacy or pharmacist applicable to the
drugs, or if no rate is included in the agreement, then at the wholesale acquisition cost.
Prohibits a pharmacy benefit manager from requiring an enrollee to pay an additional fee,
higher copay, higher coinsurance, second copay, second coinsurance, or any other increased
cost-sharing amount for a physician-administered drug when provided by a pharmacy,
pharmacist, clinic, hospital, or hospital outpatient department.
Requires the commission of any act prohibited by new law to be considered an unfair
method of competition and unfair practice or act which shall subject the violator to any and
all actions, including investigative demands, private actions, remedies, and penalties as
provided in prior law.
Effective upon signature of the governor (June 1, 2021).
(Adds R.S. 22:1020.51-1020.53)