EXPLANATION-Matter enclosed in bold-faced brackets [thus] in this bill is not enacted
and is intended to be omitted in the law.
FIRST REGULAR SESSION
SENATE BILL NO. 299
103RD GENERAL ASSEMBLY
INTRODUCED BY SENATOR MOON.
1061S.01I KRISTINA MARTIN, Secretary
AN ACT
To repeal sections 354.535 and 376.386, RSMo, and to enact in lieu thereof two new sections
relating to cost-sharing for prescription drugs.
Be it enacted by the General Assembly of the State of Missouri, as follows:
Section A. Sections 354.535 and 376.386, RSMo, are 1
repealed and two new sections enacted in lieu thereof, to be 2
known as sections 354.535 and 376.386, to read as follows:3
354.535. 1. If a pharmacy, operated by or contracted 1
with by a health maintenance organization, is closed or is 2
unable to provide health care services to an enrollee in an 3
emergency, a pharmacist may take an assignment of suc h 4
enrollee's right to reimbursement, if the policy or contract 5
provides for such reimbursement, for those goods or services 6
provided to an enrollee of a health maintenance 7
organization. No health maintenance organization shall 8
refuse to pay the pharm acist any payment due the enrollee 9
under the terms of the policy or contract. 10
2. No health maintenance organization, conducting 11
business in the state of Missouri, shall contract with a 12
pharmacy, pharmacy distributor or wholesale drug 13
distributor, nonresident or otherwise, unless such pharmacy 14
or distributor has been granted a permit or license from the 15
Missouri board of pharmacy to operate in this state. 16
3. Every health maintenance organization shall apply 17
the same coinsurance, co -payment and deductible factors to 18 SB 299 2
all drug prescriptions filled by a pharmacy provider who 19
participates in the health maintenance organization's 20
network if the provider meets the contract's explicit 21
product cost determination. If any such contract is 22
rejected by any pharmacy provider, the health maintenance 23
organization may offer other contracts necessary to comply 24
with any network adequacy provisions of this act. However, 25
nothing in this section shall be construed to prohibit the 26
health maintenance org anization from applying different 27
coinsurance, co-payment and deductible factors between 28
generic and brand name drugs. 29
4. If the cost-sharing applied by a health maintenance 30
organization exceeds the usual and customary retail price of 31
the prescription drug, enrollees shall only be required to 32
pay the usual and customary retail price of the prescription 33
drug, and no further charge to the enrollee or plan sponsor 34
shall be incurred on such prescription. 35
5. Health maintenance organizations sh all not set a 36
limit on the quantity of drugs which an enrollee may obtain 37
at any one time with a prescription, unless such limit is 38
applied uniformly to all pharmacy providers in the health 39
maintenance organization's network. 40
[5.] 6. Health maintenance organizations shall not 41
insist or mandate any physician or other licensed health 42
care practitioner to change an enrollee's maintenance drug 43
unless the provider and enrollee agree to such change. For 44
the purposes of this provision, a maintenance drug shall 45
mean a drug prescribed by a practitioner who is licensed to 46
prescribe drugs, used to treat a medical condition for a 47
period greater than thirty days. Violations of this 48
provision shall be subject to the penalties provided in 49
section 354.444. Notwithstanding other provisions of law to 50 SB 299 3
the contrary, health maintenance organizations that change 51
an enrollee's maintenance drug without the consent of the 52
provider and enrollee shall be liable for any damages 53
resulting from such change. Nothing in this subsection, 54
however, shall apply to the dispensing of generically 55
equivalent products for prescribed brand name maintenance 56
drugs as set forth in section 338.056. 57
376.386. 1. For any health carrier or health benefit 1
plan, as defined in section 376.1350, that provides 2
prescription drug coverage, if a prescription drug covered 3
by a health carrier or health benefit plan is prescribed in 4
a single dosage amount for which the particular prescription 5
drug is not manufacture d in such single dosage amount and 6
requires dispensing the particular prescription drug in a 7
combination of different manufactured dosage amounts, the 8
health carrier or health benefit plan shall only impose one 9
co-payment for the dispensing of the comb ination of 10
manufactured dosages that equal the prescribed dosage for 11
such prescription drug. Such co-payment requirement shall 12
not apply to prescriptions in excess of a one -month supply. 13
If technology does not permit such adjudication, the health 14
carrier or health benefit plan shall provide reimbursement 15
forms for the patient. 16
2. If the cost-sharing for prescription drugs applied 17
by a health carrier, as defined in section 376.1350, exceeds 18
the usual and customary retail price of the prescrip tion 19
drug, enrollees shall only be required to pay the usual and 20
customary retail price of the prescription drug, and no 21
further charge to the enrollee or plan sponsor shall be 22
incurred on such prescription. 23