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Missouri Senate Bill SB512

Missouri 2025 Regular Session

Missouri Senate Bill SB512 Compare Versions

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22 EXPLANATION-Matter enclosed in bold-faced brackets [thus] in this bill is not enacted
33 and is intended to be omitted in the law.
44 FIRST REGULAR SESSION
55 SENATE BILL NO. 512
66 103RD GENERAL ASSEMBLY
77 INTRODUCED BY SENATOR BERNSKOETTER.
88 1799S.01I KRISTINA MARTIN, Secretary
99 AN ACT
1010 To repeal sections 338.015, 376.387, and 376.388, RSMo, and to enact in lieu thereof four new
1111 sections relating to payments for prescription drugs.
1212
1313 Be it enacted by the General Assembly of the State of Missouri, as follows:
1414 Section A. Sections 338.015, 376.387, and 376.388, RSMo, 1
1515 are repealed and four new sections enacted in lieu thereof, to 2
1616 be known as sections 338.015, 376.387, 376.388, and 376.448, to 3
1717 read as follows:4
1818 338.015. 1. The provisions of sections 338.010 to 1
1919 338.015 shall not be construed to inhibit the patient's 2
2020 freedom of choice to obtain prescription services from any 3
2121 licensed pharmacist or pharmacy. [However, nothing in 4
2222 sections 338.010 to 338.315 abrogates the patient's ability 5
2323 to waive freedom of choice under any contract with regard to 6
2424 payment or coverage of prescription expense. ] 7
2525 2. All pharmacists may provide pharmaceuti cal 8
2626 consultation and advice to persons concerning the safe and 9
2727 therapeutic use of their prescription drugs. 10
2828 3. All patients shall have the right to receive a 11
2929 written prescription from their prescriber to take to the 12
3030 facility of their choice or to have an electronic 13
3131 prescription transmitted to the facility of their choice. 14
3232 4. No pharmacy benefits manager, as defined in section 15
3333 376.388, shall prohibit or redirect by contract, or 16
3434 otherwise penalize or restrict, a covered person, as defined 17 SB 512 2
3535 in section 376.387, from obtaining any of the following from 18
3636 a contracted pharmacy, as defined in section 376.388: 19
3737 (1) Prescription services, including all prescriptions 20
3838 covered by the covered person's health benefit plan; 21
3939 (2) Consultation; or 22
4040 (3) Advice. 23
4141 376.387. 1. For purposes of this section, the 1
4242 following terms shall mean: 2
4343 (1) "Covered person", [the same meaning as such term 3
4444 is defined in section 376.1257 ] a policyholder, subscriber, 4
4545 enrollee, or other individual whose prescription drug 5
4646 coverage is administered through a pharmacy benefits manager 6
4747 or a health benefit plan ; 7
4848 (2) "Health benefit plan", the same meaning as such 8
4949 term is defined in section 376.1350; 9
5050 (3) "Health carrier" or "carri er", the same meaning as 10
5151 such term is defined in section 376.1350; 11
5252 (4) "Pharmacy", the same meaning as such term is 12
5353 defined in chapter 338; 13
5454 (5) "Pharmacy benefits manager", the same meaning as 14
5555 such term is defined in section 376.388 ; 15
5656 (6) "Pharmacy benefits manager rebate aggregator", any 16
5757 entity that negotiates with a pharmaceutical manufacturer on 17
5858 behalf of a pharmacy benefits manager for a rebate; 18
5959 (7) "Pharmacy claims data", information regarding a 19
6060 prescription transaction tha t is adjudicated by a pharmacy 20
6161 benefits manager for a covered person between the pharmacy 21
6262 and the pharmacy benefits manager and between the pharmacy 22
6363 benefits manager and the health benefit plan sponsor; 23
6464 (8) "Rebate", any discount, negotiated conce ssion, or 24
6565 other payment provided by a pharmaceutical manufacturer, 25
6666 pharmacy, or health benefit plan to an entity to sell, 26 SB 512 3
6767 provide, pay, or reimburse a pharmacy or other entity in the 27
6868 state for the dispensation, coverage, or administration of a 28
6969 prescription drug on behalf of itself or another entity . 29
7070 2. No pharmacy benefits manager shall [include a 30
7171 provision in a contract entered into or modified on or after 31
7272 August 28, 2018, with a pharmacy or pharmacist that 32
7373 requires] require a covered person to make a payment for a 33
7474 prescription drug at the point of sale in an amount that 34
7575 exceeds the lesser of: 35
7676 (1) The copayment amount as required under the health 36
7777 benefit plan; [or] 37
7878 (2) The amount an individual would pay for a 38
7979 prescription if that individual paid with cash ; or 39
8080 (3) The amount equal to the difference of the final 40
8181 reimbursement amount paid to the contracted pharmacy, as 41
8282 defined in section 376.388, by the pharmacy benefits manager 42
8383 for the prescription drug minus any rebate p aid, and any 43
8484 amount paid or owed by the health benefit plan, for the 44
8585 prescription drug. 45
8686 3. A pharmacy or pharmacist shall have the right to : 46
8787 (1) Provide to a covered person information regarding 47
8888 the amount of the covered person's cost share for a 48
8989 prescription drug, the covered person's cost of an 49
9090 alternative drug, and the covered person's cost of the drug 50
9191 without adjudicating the claim through the pharmacy benefits 51
9292 manager. Neither a pharmacy nor a pharmacist shall be 52
9393 proscribed by a pharmacy benefits manager from discussing 53
9494 any such information or from selling a more affordable 54
9595 alternative to the covered person ; and 55
9696 (2) Provide to a health benefit plan sponsor any 56
9797 information, including pharmacy claims data, related to the 57 SB 512 4
9898 sponsor's health benefit plan except to the extent 58
9999 prohibited by law. 59
100100 4. (1) A pharmacy benefits manager shall not directly 60
101101 or indirectly, including indirectly through a pharmacy 61
102102 services administrative organization, reduce the amount of 62
103103 the claim at the time of the claim's adjudication or after 63
104104 the claim is adjudicated. 64
105105 (2) A pharmacy benefits manager shall not directly or 65
106106 indirectly, including indirectly through a pharmacy services 66
107107 administrative organization, charge a pharmacy a fee rel ated 67
108108 to the adjudication of a claim, including any fee related to: 68
109109 (a) The receipt and processing of a pharmacy claim; 69
110110 (b) The development or management of a claim 70
111111 processing or adjudication network; or 71
112112 (c) Participation in a claim proc essing or claim 72
113113 adjudication network. 73
114114 5. No pharmacy benefits manager shall, directly or 74
115115 indirectly, charge or hold a pharmacist or pharmacy 75
116116 responsible for any fee amount related to a claim that is 76
117117 not known at the time of the claim's adjudicati on, unless 77
118118 the amount is a result of improperly paid claims [or charges 78
119119 for administering a health benefit plan ]. 79
120120 [5. This section shall not apply with respect to 80
121121 claims under Medicare Part D, or any other plan administered 81
122122 or regulated solely un der federal law, and to the extent 82
123123 this section may be preempted under the Employee Retirement 83
124124 Income Security Act of 1974 for self -funded employer- 84
125125 sponsored health benefit plans. ] 85
126126 6. A pharmacy benefits manager shall notify in writing 86
127127 any health carrier with which it contracts if the pharmacy 87
128128 benefits manager has a conflict of interest, any commonality 88
129129 of ownership, or any other relationship, financial or 89 SB 512 5
130130 otherwise, between the pharmacy benefits manager and any 90
131131 other health carrier with which the pharmacy benefits 91
132132 manager contracts. 92
133133 7. Any pharmacy benefits manager that enters into a 93
134134 contract to sell, provide, pay, or reimburse a pharmacy in 94
135135 the state for prescription drugs on behalf of itself or 95
136136 another entity shall define and apply the term "generic", 96
137137 with respect to prescription drugs, to mean any "authorized 97
138138 generic drug", as defined in 21 CFR 314.3, approved under 98
139139 Section 505(c) of the Federal Food, Drug, and Cosmetic Act, 99
140140 as amended. 100
141141 8. An entity shall define and apply the term "rebate" 101
142142 as having the same meaning given to the term in this section 102
143143 if the entity enters into a contract to sell, provide, pay, 103
144144 negotiate rebates for, or reimburse a pharmacy, pharmacy 104
145145 benefits manager, pharmacy benefits manager affiliate a s 105
146146 defined in section 376.388, or pharmacy benefits manager 106
147147 rebate aggregator for prescription drugs on behalf of itself 107
148148 or another entity. 108
149149 9. A pharmacy benefits manager that has contracted 109
150150 with an entity to provide pharmacy benefits management 110
151151 services for such an entity or any person who negotiates 111
152152 with a pharmacy benefits manager on behalf of a purchaser of 112
153153 health care benefits shall owe a fiduciary duty to that 113
154154 entity or purchaser of health care benefits and shall 114
155155 discharge that duty in a ccordance with federal and state law. 115
156156 10. A pharmacy benefits manager shall have a duty to 116
157157 disclose to a health benefit plan sponsor. As used in this 117
158158 subsection, "duty to disclose" shall mean notifying the 118
159159 health benefit plan sponsor of material facts and actions 119
160160 taken by a pharmacy benefits manager related to the 120 SB 512 6
161161 administration of the pharmacy benefits on behalf of the 121
162162 health benefit plan sponsor that: 122
163163 (1) May increase costs to the sponsor or its covered 123
164164 persons as compared to a more pr udent action that could be 124
165165 taken; or 125
166166 (2) Present a conflict of interest between the 126
167167 interests of the sponsor and its covered persons and the 127
168168 interests of the pharmacy benefits manager. 128
169169 11. Any entity that enters into a contract to sell, 129
170170 provide, pay, or reimburse a pharmacy in the state for 130
171171 prescription drugs on behalf of itself or another entity 131
172172 shall not prohibit a health benefit plan sponsor and a 132
173173 participating pharmacy from discussing any health benefit 133
174174 plan information, including ph armacy claims data or costs. 134
175175 12. It shall be unlawful for any pharmacy benefits 135
176176 manager or any person acting on its behalf to charge a 136
177177 health benefit plan or payer a different amount for a 137
178178 prescription drug's ingredient cost or dispensing fee than 138
179179 the amount the pharmacy benefits manager reimburses a 139
180180 pharmacy for the prescription drug's ingredient cost or 140
181181 dispensing fee if the pharmacy benefits manager retains any 141
182182 amount of any such difference. 142
183183 13. The department of commerce and insurance shall 143
184184 enforce this section. 144
185185 376.388. 1. As used in this section, unless the 1
186186 context requires otherwise, the following terms shall mean: 2
187187 (1) "Contracted pharmacy" [or "pharmacy"], a pharmacy 3
188188 located in Missouri participating i n the network of a 4
189189 pharmacy benefits manager through a direct or indirect 5
190190 contract; 6
191191 (2) ["Health carrier", an entity subject to the 7
192192 insurance laws and regulations of this state that contracts 8 SB 512 7
193193 or offers to contract to provide, deliver, arrange for , pay 9
194194 for, or reimburse any of the costs of health care services, 10
195195 including a sickness and accident insurance company, a 11
196196 health maintenance organization, a nonprofit hospital and 12
197197 health service corporation, or any other entity providing a 13
198198 plan of health insurance, health benefits, or health 14
199199 services, except that such plan shall not include any 15
200200 coverage pursuant to a liability insurance policy, workers' 16
201201 compensation insurance policy, or medical payments insurance 17
202202 issued as a supplement to a liabilit y policy; 18
203203 (3)] "Maximum allowable cost", the per -unit amount 19
204204 that a pharmacy benefits manager reimburses a pharmacist for 20
205205 a prescription drug, excluding a dispensing or professional 21
206206 fee; 22
207207 [(4)] (3) "Maximum allowable cost list" or "MAC list", 23
208208 a listing of drug products that meet the standard described 24
209209 in this section; 25
210210 [(5)] (4) "Pharmacy", as such term is defined in 26
211211 chapter 338; 27
212212 [(6)] (5) "Pharmacy benefits manager", an entity that 28
213213 contracts with pharmacies on behalf of health carriers [or 29
214214 any health plan sponsored by the state or a political 30
215215 subdivision of the state ] or health benefit plans to provide 31
216216 prescription drug and pharmacist services; 32
217217 (6) "Pharmacy benefits manager affiliate", a pharmacy 33
218218 or pharmacist that di rectly or indirectly, through one or 34
219219 more intermediaries, owns or controls, is owned or 35
220220 controlled by, or is under common ownership or control with 36
221221 a pharmacy benefits manager . 37
222222 2. Upon each contract execution or renewal between a 38
223223 pharmacy benefits manager and a pharmacy or between a 39
224224 pharmacy benefits manager and a pharmacy's contracting 40 SB 512 8
225225 representative or agent, such as a pharmacy services 41
226226 administrative organization, a pharmacy benefits manager 42
227227 shall, with respect to such contract or renewal: 43
228228 (1) Include in such contract or renewal the sources 44
229229 utilized to determine maximum allowable cost and update such 45
230230 pricing information at least every seven days; and 46
231231 (2) Maintain a procedure to eliminate products from 47
232232 the maximum allowable cos t list of drugs subject to such 48
233233 pricing or modify maximum allowable cost pricing at least 49
234234 every seven days, if such drugs do not meet the standards 50
235235 and requirements of this section, in order to remain 51
236236 consistent with pricing changes in the marketplace. 52
237237 3. A pharmacy benefits manager shall reimburse 53
238238 pharmacies for drugs subject to maximum allowable cost 54
239239 pricing that has been updated to reflect market pricing at 55
240240 least every seven days as set forth under subdivision (1) of 56
241241 subsection 2 of this se ction. 57
242242 4. A pharmacy benefits manager shall not place a drug 58
243243 on a maximum allowable cost list unless there are at least 59
244244 two therapeutically equivalent multisource generic drugs, or 60
245245 at least one generic drug available from at least one 61
246246 manufacturer, generally available for purchase by network 62
247247 pharmacies from national or regional wholesalers. 63
248248 5. (1) All contracts between a pharmacy benefits 64
249249 manager and a contracted pharmacy or between a pharmacy 65
250250 benefits manager and a pharmacy's contractin g representative 66
251251 or agent, such as a pharmacy services administrative 67
252252 organization, shall include a process to internally appeal, 68
253253 investigate, and resolve disputes regarding maximum 69
254254 allowable cost pricing. The process shall include the 70
255255 following: 71 SB 512 9
256256 [(1)] (a) The right to appeal shall be limited to 72
257257 fourteen calendar days following the reimbursement of the 73
258258 initial claim; and 74
259259 [(2)] (b) A requirement that the pharmacy benefits 75
260260 manager shall respond to an appeal described in this 76
261261 subsection no later than fourteen calendar days after the 77
262262 date the appeal was received by such pharmacy benefits 78
263263 manager. 79
264264 (2) If a reimbursement to a contracted pharmacy is 80
265265 below the pharmacy's cost to purchase the drug, the pharmacy 81
266266 may decline to dispense the prescription. A pharmacy 82
267267 benefits manager shall not prohibit a pharmacy from 83
268268 declining to dispense a drug for such reason or otherwise 84
269269 retaliate against a pharmacy for doing so. 85
270270 (3) A pharmacy benefits manager shall not: 86
271271 (a) Pay or reimburse a pharmacy or pharmacist in the 87
272272 state an amount less than the amount that the pharmacy 88
273273 benefits manager reimburses a pharmacy benefits manager 89
274274 affiliate for providing the same products and pharmacist 90
275275 services, which amount shall be calculated on a per-unit 91
276276 basis using the same generic product identifier or generic 92
277277 code number; 93
278278 (b) Pay or reimburse a pharmacy or pharmacist in the 94
279279 state for the ingredient drug product component of 95
280280 pharmacist services less than the national average drug 96
281281 acquisition cost or, if the national average drug 97
282282 acquisition cost is unavailable, the wholesale acquisition 98
283283 cost; 99
284284 (c) Make or permit any reduction of payment for 100
285285 pharmacist services by a pharmacy benefits manager or a 101
286286 health care payer directly or indirectly to a pharmacy under 102
287287 a reconciliation process to an effective rate of 103 SB 512 10
288288 reimbursement including, but not limited to, generic 104
289289 effective rates, brand effective rates, direct and indirect 105
290290 remuneration fees, or any other reduction or aggregate 106
291291 reduction of payment; or 107
292292 (d) Remove from any pharmacy its legal right to civil 108
293293 recourse including, but not limited to, requiring a pharmacy 109
294294 to use arbitration to settle grievances. 110
295295 6. For appeals that are denied, the pharmacy benefits 111
296296 manager shall provide the reason for the denial and identify 112
297297 the national drug code of a drug product that may be 113
298298 purchased by contracted pharmacies at a price at or below 114
299299 the maximum allowable cost and, when applicable, may be 115
300300 substituted lawfully. 116
301301 7. If the appeal is successful, the pharmacy benefits 117
302302 manager shall: 118
303303 (1) Adjust the maximum allowable cost price that is 119
304304 the subject of the appeal effective on the day after the 120
305305 date the appeal is decided; 121
306306 (2) Apply the adjusted maximum allowabl e cost price to 122
307307 all similarly situated pharmacies as determined by the 123
308308 pharmacy benefits manager; and 124
309309 (3) Allow the pharmacy that succeeded in the appeal to 125
310310 reverse and rebill the pharmacy benefits claim giving rise 126
311311 to the appeal. 127
312312 8. Appeals shall be upheld if: 128
313313 (1) The pharmacy being reimbursed for the drug subject 129
314314 to the maximum allowable cost pricing in question was not 130
315315 reimbursed as required under subsection 3 of this section; or 131
316316 (2) The drug subject to the maximum allowable cost 132
317317 pricing in question does not meet the requirements set forth 133
318318 under subsection 4 of this section. 134 SB 512 11
319319 376.448. 1. As used in this section, the following 1
320320 terms mean: 2
321321 (1) "Cost-sharing", any co-payment, coinsurance, 3
322322 deductible, amount paid by an enrollee for health care 4
323323 services in excess of a coverage limitation, or similar 5
324324 charge required by or on behalf of an enrollee in order to 6
325325 receive a specific health care service covered by a health 7
326326 benefit plan, whether covered und er medical benefits or 8
327327 pharmacy benefits. The term "cost-sharing" shall include 9
328328 cost-sharing as defined in 42 U.S.C. Section 18022(c); 10
329329 (2) "Enrollee", the same meaning given to the term in 11
330330 section 376.1350; 12
331331 (3) "Health benefit plan", the sa me meaning given to 13
332332 the term in section 376.1350; 14
333333 (4) "Health care service", the same meaning given to 15
334334 the term in section 376.1350; 16
335335 (5) "Health carrier", the same meaning given to the 17
336336 term in section 376.1350; 18
337337 (6) "Pharmacy benefits m anager", the same meaning 19
338338 given to the term in section 376.388. 20
339339 2. When calculating an enrollee's overall contribution 21
340340 to any out-of-pocket maximum or any cost -sharing requirement 22
341341 under a health benefit plan, a health carrier or pharmacy 23
342342 benefits manager shall include any amounts paid by the 24
343343 enrollee or paid on behalf of the enrollee for any 25
344344 medication where a generic substitute for such medication is 26
345345 not available. 27
346346 3. A health carrier or pharmacy benefits manager shall 28
347347 not vary an enrollee's out-of-pocket maximum or any cost - 29
348348 sharing requirement based on, or otherwise design benefits 30
349349 in a manner that takes into account, the availability of any 31 SB 512 12
350350 cost-sharing assistance program for any medication where a 32
351351 generic substitute for such medic ation is not available. 33
352352 4. If, under federal law, application of the 34
353353 requirement under subsection 2 of this section would result 35
354354 in health savings account ineligibility under Section 223 of 36
355355 the Internal Revenue Code of 1986, as amended, the 37
356356 requirement under subsection 2 of this section shall apply 38
357357 to health savings account -qualified high deductible health 39
358358 plans with respect to any cost -sharing of such a plan after 40
359359 the enrollee has satisfied the minimum deductible under 41
360360 Section 223, except wit h respect to items or services that 42
361361 are preventive care under Section 223(c)(2)(C) of the 43
362362 Internal Revenue Code of 1986, as amended, in which case the 44
363363 requirement of subsection 2 of this section shall apply 45
364364 regardless of whether the minimum deductible under Section 46
365365 223 has been satisfied. 47
366366 5. Nothing in this section shall prohibit a health 48
367367 carrier or health benefit plan from utilizing step therapy 49
368368 in accordance with section 376.2034. 50
369369 6. The provisions of this section shall not apply to 51
370370 health benefit plans that are covered under the Labor 52
371371 Management Relations Act of 1947, 29 U.S.C. Section 141, et 53
372372 seq., as amended. 54
373373