FIRSTREGULARSESSION
HOUSEBILLNO.840
103RDGENERALASSEMBLY
INTRODUCEDBYREPRESENTATIVECOOK.
2109H.01I JOSEPHENGLER,ChiefClerk
ANACT
Torepealsections338.015,376.387,and376.388,RSMo,andtoenactinlieuthereoffour
newsectionsrelatingtopaymentsforprescriptiondrugs.
BeitenactedbytheGeneralAssemblyofthestateofMissouri,asfollows:
SectionA.Sections338.015,376.387,and376.388,RSMo,arerepealedandfour
2newsectionsenactedinlieuthereof,tobeknownassections338.015,376.387,376.388,and
3376.448,toreadasfollows:
338.015.1.Theprovisionsofsections338.010to338.015shallnotbeconstruedto
2inhibitthepatient'sfreedomofchoicetoobtainprescriptionservicesfromanylicensed
3pharmacistorpharmacy. [However,nothinginsections338.010to338.315abrogatesthe
4patient'sabilitytowaivefreedomofchoiceunderanycontractwithregardtopaymentor
5coverageofprescriptionexpense.]
6 2.Allpharmacistsmayprovidepharmaceuticalconsultationandadvicetopersons
7concerningthesafeandtherapeuticuseoftheirprescriptiondrugs.
8 3.Allpatientsshallhavetherighttoreceiveawrittenprescriptionfromtheir
9prescribertotaketothefacilityoftheirchoiceortohaveanelectronicprescription
10transmittedtothefacilityoftheirchoice.
11 4.Nopharmacybenefitsmanager,asdefinedinsection376.388,shallprohibitor
12redirectbycontract,orotherwisepenalizeorrestrict,acoveredperson,asdefinedin
13section376.387,fromobtaininganyofthefollowingfromacontractedpharmacy,as
14definedinsection376.388:
15 (1)Prescriptionservices,includingallprescriptionscoveredbythecovered
16person'shealthbenefitplan;
EXPLANATION—Matterenclosedinbold-facedbrackets[thus] intheabovebillisnotenactedandis
intendedtobeomittedfromthelaw.Matterinbold-facetypeintheabovebillisproposedlanguage. 17 (2)Consultation;or
18 (3)Advice.
376.387.1.Forpurposesofthissection,thefollowingtermsshallmean:
2 (1)"Coveredperson",[thesamemeaningassuchtermisdefinedinsection376.1257]
3apolicyholder,subscriber,enrollee,orotherindividualwhoseprescriptiondrug
4coverageisadministeredthroughapharmacybenefitsmanagerorahealthbenefitplan;
5 (2)"Healthbenefitplan",thesamemeaningassuchtermisdefinedinsection
6376.1350;
7 (3)"Healthcarrier"or"carrier",thesamemeaningassuchtermisdefinedinsection
8376.1350;
9 (4)"Pharmacy",thesamemeaningassuchtermisdefinedinchapter338;
10 (5)"Pharmacybenefitsmanager",thesamemeaningassuchtermisdefinedin
11section376.388;
12 (6)"Pharmacybenefitsmanagerrebateaggregator",anyentitythatnegotiates
13withapharmaceuticalmanufactureronbehalfofapharmacybenefitsmanagerfora
14rebate;
15 (7)"Pharmacyclaimsdata",informationregardingaprescriptiontransaction
16thatisadjudicatedbyapharmacybenefitsmanagerforacoveredpersonbetweenthe
17pharmacyandthepharmacybenefitsmanagerandbetweenthepharmacybenefits
18managerandthehealthbenefitplansponsor;
19 (8)"Rebate",anydiscount,negotiatedconcession,orotherpaymentprovided
20byapharmaceuticalmanufacturer,pharmacy,orhealthbenefitplantoanentitytosell,
21provide,pay,orreimburseapharmacyorotherentityinthestateforthedispensation,
22coverage,oradministrationofaprescriptiondrugonbehalfofitselforanotherentity.
23 2.Nopharmacybenefitsmanagershall[includeaprovisioninacontractenteredinto
24ormodifiedonorafterAugust28,2018,withapharmacyorpharmacistthatrequires]
25requireacoveredpersontomakeapaymentforaprescriptiondrugatthepointofsaleinan
26amountthatexceedsthelesserof:
27 (1)Thecopaymentamountasrequiredunderthehealthbenefitplan;[or]
28 (2)Theamountanindividualwouldpayforaprescriptionifthatindividualpaidwith
29cash;or
30 (3)Theamountequaltothedifferenceofthefinalreimbursementamountpaid
31tothecontractedpharmacy,asdefinedinsection376.388,bythepharmacybenefits
32managerfortheprescriptiondrugminusanyrebatepaid,andanyamountpaidorowed
33bythehealthbenefitplan,fortheprescriptiondrug.
34 3.Apharmacyorpharmacistshallhavetherightto:
HB840 2 35 (1)Providetoacoveredpersoninformationregardingtheamountofthecovered
36person'scostshareforaprescriptiondrug,thecoveredperson'scostofanalternativedrug,
37andthecoveredperson'scostofthedrugwithoutadjudicatingtheclaimthroughthe
38pharmacybenefitsmanager.Neitherapharmacynorapharmacistshallbeproscribedbya
39pharmacybenefitsmanagerfromdiscussinganysuchinformationorfromsellingamore
40affordablealternativetothecoveredperson; and
41 (2)Providetoahealthbenefitplansponsoranyinformation,including
42pharmacyclaimsdata,relatedtothesponsor'shealthbenefitplanexcepttotheextent
43prohibitedbylaw.
44 4.(1)Apharmacybenefitsmanagershallnotdirectlyorindirectly,including
45indirectlythroughapharmacyservicesadministrativeorganization,reducetheamount
46oftheclaimatthetimeoftheclaim'sadjudicationoraftertheclaimisadjudicated.
47 (2)Apharmacybenefitsmanagershallnotdirectlyorindirectly,including
48indirectlythroughapharmacyservicesadministrativeorganization,chargeapharmacy
49afeerelatedtotheadjudicationofaclaim,includinganyfeerelatedto:
50 (a)Thereceiptandprocessingofapharmacyclaim;
51 (b)Thedevelopmentormanagementofaclaimprocessingoradjudication
52network;or
53 (c)Participationinaclaimprocessingorclaimadjudicationnetwork.
54 5.Nopharmacybenefitsmanagershall,directlyorindirectly,chargeorholda
55pharmacistorpharmacyresponsibleforanyfeeamountrelatedtoaclaimthatisnotknownat
56thetimeoftheclaim'sadjudication,unlesstheamountisaresultofimproperlypaidclaims
57[orchargesforadministeringahealthbenefitplan].
58 [5.ThissectionshallnotapplywithrespecttoclaimsunderMedicarePartD,orany
59otherplanadministeredorregulatedsolelyunderfederallaw,andtotheextentthissection
60maybepreemptedundertheEmployeeRetirementIncomeSecurityActof1974forself-
61fundedemployer-sponsoredhealthbenefitplans.]
62 6.Apharmacybenefitsmanagershallnotifyinwritinganyhealthcarrierwithwhich
63itcontractsifthepharmacybenefitsmanagerhasaconflictofinterest,anycommonalityof
64ownership,oranyotherrelationship,financialorotherwise,betweenthepharmacybenefits
65managerandanyotherhealthcarrierwithwhichthepharmacybenefitsmanagercontracts.
66 7.Anypharmacybenefitsmanagerthatentersintoacontracttosell,provide,
67pay,orreimburseapharmacyinthestateforprescriptiondrugsonbehalfofitselfor
68anotherentityshalldefineandapplytheterm"generic",withrespecttoprescription
69drugs,tomeanany"authorizedgenericdrug",asdefinedin21CFR314.3,approved
70underSection505(c)oftheFederalFood,Drug,andCosmeticAct,asamended.
HB840 3 71 8.Anentityshalldefineandapplytheterm"rebate"ashavingthesame
72meaninggiventotheterminthissectioniftheentityentersintoacontracttosell,
73provide,pay,negotiaterebatesfor,orreimburseapharmacy,pharmacybenefits
74manager,pharmacybenefitsmanageraffiliateasdefinedinsection376.388,or
75pharmacybenefitsmanagerrebateaggregatorforprescriptiondrugsonbehalfofitself
76oranotherentity.
77 9.Apharmacybenefitsmanagerthathascontractedwithanentitytoprovide
78pharmacybenefitsmanagementservicesforsuchanentityoranypersonwhonegotiates
79withapharmacybenefitsmanageronbehalfofapurchaserofhealthcarebenefitsshall
80oweafiduciarydutytothatentityorpurchaserofhealthcarebenefitsandshall
81dischargethatdutyinaccordancewithfederalandstatelaw.
82 10.Apharmacybenefitsmanagershallhaveadutytodisclosetoahealthbenefit
83plansponsor.Asusedinthissubsection,"dutytodisclose"shallmeannotifyingthe
84healthbenefitplansponsorofmaterialfactsandactionstakenbyapharmacybenefits
85managerrelatedtotheadministrationofthepharmacybenefitsonbehalfofthehealth
86benefitplansponsorthat:
87 (1)Mayincreasecoststothesponsororitscoveredpersonsascomparedtoa
88moreprudentactionthatcouldbetaken;or
89 (2)Presentaconflictofinterestbetweentheinterestsofthesponsorandits
90coveredpersonsandtheinterestsofthepharmacybenefitsmanager.
91 11.Anyentitythatentersintoacontracttosell,provide,pay,orreimbursea
92pharmacyinthestateforprescriptiondrugsonbehalfofitselforanotherentityshall
93notprohibitahealthbenefitplansponsorandaparticipatingpharmacyfromdiscussing
94anyhealthbenefitplaninformation,includingpharmacyclaimsdataorcosts.
95 12.Itshallbeunlawfulforanypharmacybenefitsmanageroranypersonacting
96onitsbehalftochargeahealthbenefitplanorpayeradifferentamountfora
97prescriptiondrug'singredientcostordispensingfeethantheamountthepharmacy
98benefitsmanagerreimbursesapharmacyfortheprescriptiondrug'singredientcostor
99dispensingfeeifthepharmacybenefitsmanagerretainsanyamountofanysuch
100difference.
101 13.Thedepartmentofcommerceandinsuranceshallenforcethissection.
376.388.1.Asusedinthissection,unlessthecontextrequiresotherwise,the
2followingtermsshallmean:
3 (1)"Contractedpharmacy"[or"pharmacy"], apharmacylocatedinMissouri
4participatinginthenetworkofapharmacybenefitsmanagerthroughadirectorindirect
5contract;
HB840 4 6 (2)["Healthcarrier",anentitysubjecttotheinsurancelawsandregulationsofthis
7statethatcontractsorofferstocontracttoprovide,deliver,arrangefor,payfor,orreimburse
8anyofthecostsofhealthcareservices,includingasicknessandaccidentinsurancecompany,
9ahealthmaintenanceorganization,anonprofithospitalandhealthservicecorporation,orany
10otherentityprovidingaplanofhealthinsurance,healthbenefits,orhealthservices,except
11thatsuchplanshallnotincludeanycoveragepursuanttoaliabilityinsurancepolicy,workers'
12compensationinsurancepolicy,ormedicalpaymentsinsuranceissuedasasupplementtoa
13liabilitypolicy;
14 (3)] "Maximumallowablecost",theper-unitamountthatapharmacybenefits
15managerreimbursesapharmacistforaprescriptiondrug,excludingadispensingor
16professionalfee;
17 [(4)](3)"Maximumallowablecostlist"or"MAClist",alistingofdrugproductsthat
18meetthestandarddescribedinthissection;
19 [(5)](4)"Pharmacy",assuchtermisdefinedinchapter338;
20 [(6)](5)"Pharmacybenefitsmanager",anentitythatcontractswithpharmacieson
21behalfofhealthcarriers[oranyhealthplansponsoredbythestateorapoliticalsubdivisionof
22thestate]orhealthbenefitplanstoprovideprescriptiondrugandpharmacistservices;
23 (6)"Pharmacybenefitsmanageraffiliate",apharmacyorpharmacistthat
24directlyorindirectly,throughoneormoreintermediaries,ownsorcontrols,isownedor
25controlledby,orisundercommonownershiporcontrolwithapharmacybenefits
26manager.
27 2.Uponeachcontractexecutionorrenewalbetweenapharmacybenefitsmanager
28andapharmacyorbetweenapharmacybenefitsmanagerandapharmacy'scontracting
29representativeoragent,suchasapharmacyservicesadministrativeorganization,apharmacy
30benefitsmanagershall,withrespecttosuchcontractorrenewal:
31 (1)Includeinsuchcontractorrenewalthesourcesutilizedtodeterminemaximum
32allowablecostandupdatesuchpricinginformationatleasteverysevendays;and
33 (2)Maintainaproceduretoeliminateproductsfromthemaximumallowablecostlist
34ofdrugssubjecttosuchpricingormodifymaximumallowablecostpricingatleastevery
35sevendays,ifsuchdrugsdonotmeetthestandardsandrequirementsofthissection,inorder
36toremainconsistentwithpricingchangesinthemarketplace.
37 3.Apharmacybenefitsmanagershallreimbursepharmaciesfordrugssubjectto
38maximumallowablecostpricingthathasbeenupdatedtoreflectmarketpricingatleastevery
39sevendaysassetforthundersubdivision(1)ofsubsection2ofthissection.
40 4.Apharmacybenefitsmanagershallnotplaceadrugonamaximumallowablecost
41listunlessthereareatleasttwotherapeuticallyequivalentmultisourcegenericdrugs,orat
HB840 5 42leastonegenericdrugavailablefromatleastonemanufacturer,generallyavailablefor
43purchasebynetworkpharmaciesfromnationalorregionalwholesalers.
44 5.(1)Allcontractsbetweenapharmacybenefitsmanagerandacontractedpharmacy
45orbetweenapharmacybenefitsmanagerandapharmacy'scontractingrepresentativeor
46agent,suchasapharmacyservicesadministrativeorganization,shallincludeaprocessto
47internallyappeal,investigate,andresolvedisputesregardingmaximumallowablecost
48pricing.Theprocessshallincludethefollowing:
49 [(1)](a)Therighttoappealshallbelimitedtofourteencalendardaysfollowingthe
50reimbursementoftheinitialclaim;and
51 [(2)](b)Arequirementthatthepharmacybenefitsmanagershallrespondtoan
52appealdescribedinthissubsectionnolaterthanfourteencalendardaysafterthedatethe
53appealwasreceivedbysuchpharmacybenefitsmanager.
54 (2)Ifareimbursementtoacontractedpharmacyisbelowthepharmacy'scostto
55purchasethedrug,thepharmacymaydeclinetodispensetheprescription.Apharmacy
56benefitsmanagershallnotprohibitapharmacyfromdecliningtodispenseadrugfor
57suchreasonorotherwiseretaliateagainstapharmacyfordoingso.
58 (3)Apharmacybenefitsmanagershallnot:
59 (a)Payorreimburseapharmacyorpharmacistinthestateanamountlessthan
60theamountthatthepharmacybenefitsmanagerreimbursesapharmacybenefits
61manageraffiliateforprovidingthesameproductsandpharmacistservices,which
62amountshallbecalculatedonaper-unitbasisusingthesamegenericproductidentifier
63orgenericcodenumber;
64 (b)Payorreimburseapharmacyorpharmacistinthestatefortheingredient
65drugproductcomponentofpharmacistserviceslessthanthenationalaveragedrug
66acquisitioncostor,ifthenationalaveragedrugacquisitioncostisunavailable,the
67wholesaleacquisitioncost;
68 (c)Makeorpermitanyreductionofpaymentforpharmacistservicesbya
69pharmacybenefitsmanagerorahealthcarepayerdirectlyorindirectlytoapharmacy
70underareconciliationprocesstoaneffectiverateofreimbursementincluding,butnot
71limitedto,genericeffectiverates,brandeffectiverates,directandindirectremuneration
72fees,oranyotherreductionoraggregatereductionofpayment;or
73 (d)Removefromanypharmacyitslegalrighttocivilrecourseincluding,butnot
74limitedto,requiringapharmacytousearbitrationtosettlegrievances.
75 6.Forappealsthataredenied,thepharmacybenefitsmanagershallprovidethe
76reasonforthedenialandidentifythenationaldrugcodeofadrugproductthatmaybe
77purchasedbycontractedpharmaciesatapriceatorbelowthemaximumallowablecostand,
78whenapplicable,maybesubstitutedlawfully.
HB840 6 79 7.Iftheappealissuccessful,thepharmacybenefitsmanagershall:
80 (1)Adjustthemaximumallowablecostpricethatisthesubjectoftheappealeffective
81onthedayafterthedatetheappealisdecided;
82 (2)Applytheadjustedmaximumallowablecostpricetoallsimilarlysituated
83pharmaciesasdeterminedbythepharmacybenefitsmanager;and
84 (3)Allowthepharmacythatsucceededintheappealtoreverseandrebillthe
85pharmacybenefitsclaimgivingrisetotheappeal.
86 8.Appealsshallbeupheldif:
87 (1)Thepharmacybeingreimbursedforthedrugsubjecttothemaximumallowable
88costpricinginquestionwasnotreimbursedasrequiredundersubsection3ofthissection;or
89 (2)Thedrugsubjecttothemaximumallowablecostpricinginquestiondoesnotmeet
90therequirementssetforthundersubsection4ofthissection.
376.448.1.Asusedinthissection,thefollowingtermsmean:
2 (1)"Cost-sharing",anyco-payment,coinsurance,deductible,amountpaidby
3anenrolleeforhealthcareservicesinexcessofacoveragelimitation,orsimilarcharge
4requiredbyoronbehalfofanenrolleeinordertoreceiveaspecifichealthcareservice
5coveredbyahealthbenefitplan,whethercoveredundermedicalbenefitsorpharmacy
6benefits.Theterm"cost-sharing"shallincludecost-sharingasdefinedin42U.S.C.
7Section18022(c);
8 (2)"Enrollee",thesamemeaninggiventotheterminsection376.1350;
9 (3)"Healthbenefitplan",thesamemeaninggiventotheterminsection
10376.1350;
11 (4)"Healthcareservice",thesamemeaninggiventotheterminsection
12376.1350;
13 (5)"Healthcarrier",thesamemeaninggiventotheterminsection376.1350;
14 (6)"Pharmacybenefitsmanager",thesamemeaninggiventotheterminsection
15376.388.
16 2.Whencalculatinganenrollee'soverallcontributiontoanyout-of-pocket
17maximumoranycost-sharingrequirementunderahealthbenefitplan,ahealthcarrier
18orpharmacybenefitsmanagershallincludeanyamountspaidbytheenrolleeorpaid
19onbehalfoftheenrolleeforanymedicationwhereagenericsubstituteforsuch
20medicationisnotavailable.
21 3.Ahealthcarrierorpharmacybenefitsmanagershallnotvaryanenrollee's
22out-of-pocketmaximumoranycost-sharingrequirementbasedon,orotherwisedesign
23benefitsinamannerthattakesintoaccount,theavailabilityofanycost-sharing
24assistanceprogramforanymedicationwhereagenericsubstituteforsuchmedicationis
25notavailable.
HB840 7 26 4.If,underfederallaw,applicationoftherequirementundersubsection2ofthis
27sectionwouldresultinhealthsavingsaccountineligibilityunderSection223ofthe
28InternalRevenueCodeof1986,asamended,therequirementundersubsection2ofthis
29sectionshallapplytohealthsavingsaccount-qualifiedhighdeductiblehealthplanswith
30respecttoanycost-sharingofsuchaplanaftertheenrolleehassatisfiedtheminimum
31deductibleunderSection223,exceptwithrespecttoitemsorservicesthatare
32preventivecareunderSection223(c)(2)(C)oftheInternalRevenueCodeof1986,as
33amended,inwhichcasetherequirementofsubsection2ofthissectionshallapply
34regardlessofwhethertheminimumdeductibleunderSection223hasbeensatisfied.
35 5.Nothinginthissectionshallprohibitahealthcarrierorhealthbenefitplan
36fromutilizingsteptherapyinaccordancewithsection376.2034.
37 6.Theprovisionsofthissectionshallnotapplytohealthbenefitplansthatare
38coveredundertheLaborManagementRelationsActof1947,29U.S.C.Section141et
39seq.,asamended.
âś”
HB840 8