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Missouri House Bill HB840

Missouri 2025 Regular Session

Missouri House Bill HB840 Compare Versions

Only one version of the bill is available at this time.
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11 FIRSTREGULARSESSION
22 HOUSEBILLNO.840
33 103RDGENERALASSEMBLY
44 INTRODUCEDBYREPRESENTATIVECOOK.
55 2109H.01I JOSEPHENGLER,ChiefClerk
66 ANACT
77 Torepealsections338.015,376.387,and376.388,RSMo,andtoenactinlieuthereoffour
88 newsectionsrelatingtopaymentsforprescriptiondrugs.
99 BeitenactedbytheGeneralAssemblyofthestateofMissouri,asfollows:
1010 SectionA.Sections338.015,376.387,and376.388,RSMo,arerepealedandfour
1111 2newsectionsenactedinlieuthereof,tobeknownassections338.015,376.387,376.388,and
1212 3376.448,toreadasfollows:
1313 338.015.1.Theprovisionsofsections338.010to338.015shallnotbeconstruedto
1414 2inhibitthepatient'sfreedomofchoicetoobtainprescriptionservicesfromanylicensed
1515 3pharmacistorpharmacy. [However,nothinginsections338.010to338.315abrogatesthe
1616 4patient'sabilitytowaivefreedomofchoiceunderanycontractwithregardtopaymentor
1717 5coverageofprescriptionexpense.]
1818 6 2.Allpharmacistsmayprovidepharmaceuticalconsultationandadvicetopersons
1919 7concerningthesafeandtherapeuticuseoftheirprescriptiondrugs.
2020 8 3.Allpatientsshallhavetherighttoreceiveawrittenprescriptionfromtheir
2121 9prescribertotaketothefacilityoftheirchoiceortohaveanelectronicprescription
2222 10transmittedtothefacilityoftheirchoice.
2323 11 4.Nopharmacybenefitsmanager,asdefinedinsection376.388,shallprohibitor
2424 12redirectbycontract,orotherwisepenalizeorrestrict,acoveredperson,asdefinedin
2525 13section376.387,fromobtaininganyofthefollowingfromacontractedpharmacy,as
2626 14definedinsection376.388:
2727 15 (1)Prescriptionservices,includingallprescriptionscoveredbythecovered
2828 16person'shealthbenefitplan;
2929 EXPLANATION—Matterenclosedinbold-facedbrackets[thus] intheabovebillisnotenactedandis
3030 intendedtobeomittedfromthelaw.Matterinbold-facetypeintheabovebillisproposedlanguage. 17 (2)Consultation;or
3131 18 (3)Advice.
3232 376.387.1.Forpurposesofthissection,thefollowingtermsshallmean:
3333 2 (1)"Coveredperson",[thesamemeaningassuchtermisdefinedinsection376.1257]
3434 3apolicyholder,subscriber,enrollee,orotherindividualwhoseprescriptiondrug
3535 4coverageisadministeredthroughapharmacybenefitsmanagerorahealthbenefitplan;
3636 5 (2)"Healthbenefitplan",thesamemeaningassuchtermisdefinedinsection
3737 6376.1350;
3838 7 (3)"Healthcarrier"or"carrier",thesamemeaningassuchtermisdefinedinsection
3939 8376.1350;
4040 9 (4)"Pharmacy",thesamemeaningassuchtermisdefinedinchapter338;
4141 10 (5)"Pharmacybenefitsmanager",thesamemeaningassuchtermisdefinedin
4242 11section376.388;
4343 12 (6)"Pharmacybenefitsmanagerrebateaggregator",anyentitythatnegotiates
4444 13withapharmaceuticalmanufactureronbehalfofapharmacybenefitsmanagerfora
4545 14rebate;
4646 15 (7)"Pharmacyclaimsdata",informationregardingaprescriptiontransaction
4747 16thatisadjudicatedbyapharmacybenefitsmanagerforacoveredpersonbetweenthe
4848 17pharmacyandthepharmacybenefitsmanagerandbetweenthepharmacybenefits
4949 18managerandthehealthbenefitplansponsor;
5050 19 (8)"Rebate",anydiscount,negotiatedconcession,orotherpaymentprovided
5151 20byapharmaceuticalmanufacturer,pharmacy,orhealthbenefitplantoanentitytosell,
5252 21provide,pay,orreimburseapharmacyorotherentityinthestateforthedispensation,
5353 22coverage,oradministrationofaprescriptiondrugonbehalfofitselforanotherentity.
5454 23 2.Nopharmacybenefitsmanagershall[includeaprovisioninacontractenteredinto
5555 24ormodifiedonorafterAugust28,2018,withapharmacyorpharmacistthatrequires]
5656 25requireacoveredpersontomakeapaymentforaprescriptiondrugatthepointofsaleinan
5757 26amountthatexceedsthelesserof:
5858 27 (1)Thecopaymentamountasrequiredunderthehealthbenefitplan;[or]
5959 28 (2)Theamountanindividualwouldpayforaprescriptionifthatindividualpaidwith
6060 29cash;or
6161 30 (3)Theamountequaltothedifferenceofthefinalreimbursementamountpaid
6262 31tothecontractedpharmacy,asdefinedinsection376.388,bythepharmacybenefits
6363 32managerfortheprescriptiondrugminusanyrebatepaid,andanyamountpaidorowed
6464 33bythehealthbenefitplan,fortheprescriptiondrug.
6565 34 3.Apharmacyorpharmacistshallhavetherightto:
6666 HB840 2 35 (1)Providetoacoveredpersoninformationregardingtheamountofthecovered
6767 36person'scostshareforaprescriptiondrug,thecoveredperson'scostofanalternativedrug,
6868 37andthecoveredperson'scostofthedrugwithoutadjudicatingtheclaimthroughthe
6969 38pharmacybenefitsmanager.Neitherapharmacynorapharmacistshallbeproscribedbya
7070 39pharmacybenefitsmanagerfromdiscussinganysuchinformationorfromsellingamore
7171 40affordablealternativetothecoveredperson; and
7272 41 (2)Providetoahealthbenefitplansponsoranyinformation,including
7373 42pharmacyclaimsdata,relatedtothesponsor'shealthbenefitplanexcepttotheextent
7474 43prohibitedbylaw.
7575 44 4.(1)Apharmacybenefitsmanagershallnotdirectlyorindirectly,including
7676 45indirectlythroughapharmacyservicesadministrativeorganization,reducetheamount
7777 46oftheclaimatthetimeoftheclaim'sadjudicationoraftertheclaimisadjudicated.
7878 47 (2)Apharmacybenefitsmanagershallnotdirectlyorindirectly,including
7979 48indirectlythroughapharmacyservicesadministrativeorganization,chargeapharmacy
8080 49afeerelatedtotheadjudicationofaclaim,includinganyfeerelatedto:
8181 50 (a)Thereceiptandprocessingofapharmacyclaim;
8282 51 (b)Thedevelopmentormanagementofaclaimprocessingoradjudication
8383 52network;or
8484 53 (c)Participationinaclaimprocessingorclaimadjudicationnetwork.
8585 54 5.Nopharmacybenefitsmanagershall,directlyorindirectly,chargeorholda
8686 55pharmacistorpharmacyresponsibleforanyfeeamountrelatedtoaclaimthatisnotknownat
8787 56thetimeoftheclaim'sadjudication,unlesstheamountisaresultofimproperlypaidclaims
8888 57[orchargesforadministeringahealthbenefitplan].
8989 58 [5.ThissectionshallnotapplywithrespecttoclaimsunderMedicarePartD,orany
9090 59otherplanadministeredorregulatedsolelyunderfederallaw,andtotheextentthissection
9191 60maybepreemptedundertheEmployeeRetirementIncomeSecurityActof1974forself-
9292 61fundedemployer-sponsoredhealthbenefitplans.]
9393 62 6.Apharmacybenefitsmanagershallnotifyinwritinganyhealthcarrierwithwhich
9494 63itcontractsifthepharmacybenefitsmanagerhasaconflictofinterest,anycommonalityof
9595 64ownership,oranyotherrelationship,financialorotherwise,betweenthepharmacybenefits
9696 65managerandanyotherhealthcarrierwithwhichthepharmacybenefitsmanagercontracts.
9797 66 7.Anypharmacybenefitsmanagerthatentersintoacontracttosell,provide,
9898 67pay,orreimburseapharmacyinthestateforprescriptiondrugsonbehalfofitselfor
9999 68anotherentityshalldefineandapplytheterm"generic",withrespecttoprescription
100100 69drugs,tomeanany"authorizedgenericdrug",asdefinedin21CFR314.3,approved
101101 70underSection505(c)oftheFederalFood,Drug,andCosmeticAct,asamended.
102102 HB840 3 71 8.Anentityshalldefineandapplytheterm"rebate"ashavingthesame
103103 72meaninggiventotheterminthissectioniftheentityentersintoacontracttosell,
104104 73provide,pay,negotiaterebatesfor,orreimburseapharmacy,pharmacybenefits
105105 74manager,pharmacybenefitsmanageraffiliateasdefinedinsection376.388,or
106106 75pharmacybenefitsmanagerrebateaggregatorforprescriptiondrugsonbehalfofitself
107107 76oranotherentity.
108108 77 9.Apharmacybenefitsmanagerthathascontractedwithanentitytoprovide
109109 78pharmacybenefitsmanagementservicesforsuchanentityoranypersonwhonegotiates
110110 79withapharmacybenefitsmanageronbehalfofapurchaserofhealthcarebenefitsshall
111111 80oweafiduciarydutytothatentityorpurchaserofhealthcarebenefitsandshall
112112 81dischargethatdutyinaccordancewithfederalandstatelaw.
113113 82 10.Apharmacybenefitsmanagershallhaveadutytodisclosetoahealthbenefit
114114 83plansponsor.Asusedinthissubsection,"dutytodisclose"shallmeannotifyingthe
115115 84healthbenefitplansponsorofmaterialfactsandactionstakenbyapharmacybenefits
116116 85managerrelatedtotheadministrationofthepharmacybenefitsonbehalfofthehealth
117117 86benefitplansponsorthat:
118118 87 (1)Mayincreasecoststothesponsororitscoveredpersonsascomparedtoa
119119 88moreprudentactionthatcouldbetaken;or
120120 89 (2)Presentaconflictofinterestbetweentheinterestsofthesponsorandits
121121 90coveredpersonsandtheinterestsofthepharmacybenefitsmanager.
122122 91 11.Anyentitythatentersintoacontracttosell,provide,pay,orreimbursea
123123 92pharmacyinthestateforprescriptiondrugsonbehalfofitselforanotherentityshall
124124 93notprohibitahealthbenefitplansponsorandaparticipatingpharmacyfromdiscussing
125125 94anyhealthbenefitplaninformation,includingpharmacyclaimsdataorcosts.
126126 95 12.Itshallbeunlawfulforanypharmacybenefitsmanageroranypersonacting
127127 96onitsbehalftochargeahealthbenefitplanorpayeradifferentamountfora
128128 97prescriptiondrug'singredientcostordispensingfeethantheamountthepharmacy
129129 98benefitsmanagerreimbursesapharmacyfortheprescriptiondrug'singredientcostor
130130 99dispensingfeeifthepharmacybenefitsmanagerretainsanyamountofanysuch
131131 100difference.
132132 101 13.Thedepartmentofcommerceandinsuranceshallenforcethissection.
133133 376.388.1.Asusedinthissection,unlessthecontextrequiresotherwise,the
134134 2followingtermsshallmean:
135135 3 (1)"Contractedpharmacy"[or"pharmacy"], apharmacylocatedinMissouri
136136 4participatinginthenetworkofapharmacybenefitsmanagerthroughadirectorindirect
137137 5contract;
138138 HB840 4 6 (2)["Healthcarrier",anentitysubjecttotheinsurancelawsandregulationsofthis
139139 7statethatcontractsorofferstocontracttoprovide,deliver,arrangefor,payfor,orreimburse
140140 8anyofthecostsofhealthcareservices,includingasicknessandaccidentinsurancecompany,
141141 9ahealthmaintenanceorganization,anonprofithospitalandhealthservicecorporation,orany
142142 10otherentityprovidingaplanofhealthinsurance,healthbenefits,orhealthservices,except
143143 11thatsuchplanshallnotincludeanycoveragepursuanttoaliabilityinsurancepolicy,workers'
144144 12compensationinsurancepolicy,ormedicalpaymentsinsuranceissuedasasupplementtoa
145145 13liabilitypolicy;
146146 14 (3)] "Maximumallowablecost",theper-unitamountthatapharmacybenefits
147147 15managerreimbursesapharmacistforaprescriptiondrug,excludingadispensingor
148148 16professionalfee;
149149 17 [(4)](3)"Maximumallowablecostlist"or"MAClist",alistingofdrugproductsthat
150150 18meetthestandarddescribedinthissection;
151151 19 [(5)](4)"Pharmacy",assuchtermisdefinedinchapter338;
152152 20 [(6)](5)"Pharmacybenefitsmanager",anentitythatcontractswithpharmacieson
153153 21behalfofhealthcarriers[oranyhealthplansponsoredbythestateorapoliticalsubdivisionof
154154 22thestate]orhealthbenefitplanstoprovideprescriptiondrugandpharmacistservices;
155155 23 (6)"Pharmacybenefitsmanageraffiliate",apharmacyorpharmacistthat
156156 24directlyorindirectly,throughoneormoreintermediaries,ownsorcontrols,isownedor
157157 25controlledby,orisundercommonownershiporcontrolwithapharmacybenefits
158158 26manager.
159159 27 2.Uponeachcontractexecutionorrenewalbetweenapharmacybenefitsmanager
160160 28andapharmacyorbetweenapharmacybenefitsmanagerandapharmacy'scontracting
161161 29representativeoragent,suchasapharmacyservicesadministrativeorganization,apharmacy
162162 30benefitsmanagershall,withrespecttosuchcontractorrenewal:
163163 31 (1)Includeinsuchcontractorrenewalthesourcesutilizedtodeterminemaximum
164164 32allowablecostandupdatesuchpricinginformationatleasteverysevendays;and
165165 33 (2)Maintainaproceduretoeliminateproductsfromthemaximumallowablecostlist
166166 34ofdrugssubjecttosuchpricingormodifymaximumallowablecostpricingatleastevery
167167 35sevendays,ifsuchdrugsdonotmeetthestandardsandrequirementsofthissection,inorder
168168 36toremainconsistentwithpricingchangesinthemarketplace.
169169 37 3.Apharmacybenefitsmanagershallreimbursepharmaciesfordrugssubjectto
170170 38maximumallowablecostpricingthathasbeenupdatedtoreflectmarketpricingatleastevery
171171 39sevendaysassetforthundersubdivision(1)ofsubsection2ofthissection.
172172 40 4.Apharmacybenefitsmanagershallnotplaceadrugonamaximumallowablecost
173173 41listunlessthereareatleasttwotherapeuticallyequivalentmultisourcegenericdrugs,orat
174174 HB840 5 42leastonegenericdrugavailablefromatleastonemanufacturer,generallyavailablefor
175175 43purchasebynetworkpharmaciesfromnationalorregionalwholesalers.
176176 44 5.(1)Allcontractsbetweenapharmacybenefitsmanagerandacontractedpharmacy
177177 45orbetweenapharmacybenefitsmanagerandapharmacy'scontractingrepresentativeor
178178 46agent,suchasapharmacyservicesadministrativeorganization,shallincludeaprocessto
179179 47internallyappeal,investigate,andresolvedisputesregardingmaximumallowablecost
180180 48pricing.Theprocessshallincludethefollowing:
181181 49 [(1)](a)Therighttoappealshallbelimitedtofourteencalendardaysfollowingthe
182182 50reimbursementoftheinitialclaim;and
183183 51 [(2)](b)Arequirementthatthepharmacybenefitsmanagershallrespondtoan
184184 52appealdescribedinthissubsectionnolaterthanfourteencalendardaysafterthedatethe
185185 53appealwasreceivedbysuchpharmacybenefitsmanager.
186186 54 (2)Ifareimbursementtoacontractedpharmacyisbelowthepharmacy'scostto
187187 55purchasethedrug,thepharmacymaydeclinetodispensetheprescription.Apharmacy
188188 56benefitsmanagershallnotprohibitapharmacyfromdecliningtodispenseadrugfor
189189 57suchreasonorotherwiseretaliateagainstapharmacyfordoingso.
190190 58 (3)Apharmacybenefitsmanagershallnot:
191191 59 (a)Payorreimburseapharmacyorpharmacistinthestateanamountlessthan
192192 60theamountthatthepharmacybenefitsmanagerreimbursesapharmacybenefits
193193 61manageraffiliateforprovidingthesameproductsandpharmacistservices,which
194194 62amountshallbecalculatedonaper-unitbasisusingthesamegenericproductidentifier
195195 63orgenericcodenumber;
196196 64 (b)Payorreimburseapharmacyorpharmacistinthestatefortheingredient
197197 65drugproductcomponentofpharmacistserviceslessthanthenationalaveragedrug
198198 66acquisitioncostor,ifthenationalaveragedrugacquisitioncostisunavailable,the
199199 67wholesaleacquisitioncost;
200200 68 (c)Makeorpermitanyreductionofpaymentforpharmacistservicesbya
201201 69pharmacybenefitsmanagerorahealthcarepayerdirectlyorindirectlytoapharmacy
202202 70underareconciliationprocesstoaneffectiverateofreimbursementincluding,butnot
203203 71limitedto,genericeffectiverates,brandeffectiverates,directandindirectremuneration
204204 72fees,oranyotherreductionoraggregatereductionofpayment;or
205205 73 (d)Removefromanypharmacyitslegalrighttocivilrecourseincluding,butnot
206206 74limitedto,requiringapharmacytousearbitrationtosettlegrievances.
207207 75 6.Forappealsthataredenied,thepharmacybenefitsmanagershallprovidethe
208208 76reasonforthedenialandidentifythenationaldrugcodeofadrugproductthatmaybe
209209 77purchasedbycontractedpharmaciesatapriceatorbelowthemaximumallowablecostand,
210210 78whenapplicable,maybesubstitutedlawfully.
211211 HB840 6 79 7.Iftheappealissuccessful,thepharmacybenefitsmanagershall:
212212 80 (1)Adjustthemaximumallowablecostpricethatisthesubjectoftheappealeffective
213213 81onthedayafterthedatetheappealisdecided;
214214 82 (2)Applytheadjustedmaximumallowablecostpricetoallsimilarlysituated
215215 83pharmaciesasdeterminedbythepharmacybenefitsmanager;and
216216 84 (3)Allowthepharmacythatsucceededintheappealtoreverseandrebillthe
217217 85pharmacybenefitsclaimgivingrisetotheappeal.
218218 86 8.Appealsshallbeupheldif:
219219 87 (1)Thepharmacybeingreimbursedforthedrugsubjecttothemaximumallowable
220220 88costpricinginquestionwasnotreimbursedasrequiredundersubsection3ofthissection;or
221221 89 (2)Thedrugsubjecttothemaximumallowablecostpricinginquestiondoesnotmeet
222222 90therequirementssetforthundersubsection4ofthissection.
223223 376.448.1.Asusedinthissection,thefollowingtermsmean:
224224 2 (1)"Cost-sharing",anyco-payment,coinsurance,deductible,amountpaidby
225225 3anenrolleeforhealthcareservicesinexcessofacoveragelimitation,orsimilarcharge
226226 4requiredbyoronbehalfofanenrolleeinordertoreceiveaspecifichealthcareservice
227227 5coveredbyahealthbenefitplan,whethercoveredundermedicalbenefitsorpharmacy
228228 6benefits.Theterm"cost-sharing"shallincludecost-sharingasdefinedin42U.S.C.
229229 7Section18022(c);
230230 8 (2)"Enrollee",thesamemeaninggiventotheterminsection376.1350;
231231 9 (3)"Healthbenefitplan",thesamemeaninggiventotheterminsection
232232 10376.1350;
233233 11 (4)"Healthcareservice",thesamemeaninggiventotheterminsection
234234 12376.1350;
235235 13 (5)"Healthcarrier",thesamemeaninggiventotheterminsection376.1350;
236236 14 (6)"Pharmacybenefitsmanager",thesamemeaninggiventotheterminsection
237237 15376.388.
238238 16 2.Whencalculatinganenrollee'soverallcontributiontoanyout-of-pocket
239239 17maximumoranycost-sharingrequirementunderahealthbenefitplan,ahealthcarrier
240240 18orpharmacybenefitsmanagershallincludeanyamountspaidbytheenrolleeorpaid
241241 19onbehalfoftheenrolleeforanymedicationwhereagenericsubstituteforsuch
242242 20medicationisnotavailable.
243243 21 3.Ahealthcarrierorpharmacybenefitsmanagershallnotvaryanenrollee's
244244 22out-of-pocketmaximumoranycost-sharingrequirementbasedon,orotherwisedesign
245245 23benefitsinamannerthattakesintoaccount,theavailabilityofanycost-sharing
246246 24assistanceprogramforanymedicationwhereagenericsubstituteforsuchmedicationis
247247 25notavailable.
248248 HB840 7 26 4.If,underfederallaw,applicationoftherequirementundersubsection2ofthis
249249 27sectionwouldresultinhealthsavingsaccountineligibilityunderSection223ofthe
250250 28InternalRevenueCodeof1986,asamended,therequirementundersubsection2ofthis
251251 29sectionshallapplytohealthsavingsaccount-qualifiedhighdeductiblehealthplanswith
252252 30respecttoanycost-sharingofsuchaplanaftertheenrolleehassatisfiedtheminimum
253253 31deductibleunderSection223,exceptwithrespecttoitemsorservicesthatare
254254 32preventivecareunderSection223(c)(2)(C)oftheInternalRevenueCodeof1986,as
255255 33amended,inwhichcasetherequirementofsubsection2ofthissectionshallapply
256256 34regardlessofwhethertheminimumdeductibleunderSection223hasbeensatisfied.
257257 35 5.Nothinginthissectionshallprohibitahealthcarrierorhealthbenefitplan
258258 36fromutilizingsteptherapyinaccordancewithsection376.2034.
259259 37 6.Theprovisionsofthissectionshallnotapplytohealthbenefitplansthatare
260260 38coveredundertheLaborManagementRelationsActof1947,29U.S.C.Section141et
261261 39seq.,asamended.
262262 âś”
263263 HB840 8