Oklahoma 2023 Regular Session

Oklahoma House Bill HB1843 Compare Versions

Version 1 (Old)

Version 2 (New)

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1		-	An Act
2		-	ENROLLED HOUSE
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	30	+	April 12, 2023
	31	+	AS AMENDED
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	33	+	ENGROSSED HOUSE
3	34		BILL NO. 1843 By: Kerbs, Davis, Newton,
4	35		Grego, Maynard, Burns,
5		-	Roberts and Talley of the
	36	+	Roberts, and Talley of the
6	37		House
7	38
8	39		and
9	40
10		-	McCortney, Bullard ~~and~~
11		-	~~Stephens of~~ the Senate
	41	+	McCortney and Bullard of
	42	+	the Senate
12	43
13	44
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16		-
17		-	An Act relating to pharmacy benefit managers ;
18		-	amending 36 O.S. 2021, Section 6962, as amended by
19		-	Section 2, Chapter 38, O.S.L. 20 22 (36 O.S. Supp.
20		-	2022, Section 6962), which relates to compliance
21		-	review; replacing Insurance Commissioner with
22		-	Attorney General; amending 36 O.S. 2021 , Section
23		-	6965, which relates to power to inves tigate;
24		-	replacing investigative authority with the Attor ney
25		-	General; amending 36 O.S. 2021, Section 6966.1, as
26		-	amended by Section 3, Chapter 38, O.S.L. 2022 (36
27		-	O.S. Supp. 2022, Section 6966.1), which relates to
28		-	violations, penalties, and hearings; replacing
29		-	enforcement authority with the Attorney General ;
30		-	and providing an effective date.
	47	+	[ pharmacy benefit managers - compliance review -
	48	+	Attorney General - investigative authority -
	49	+	violations, penalties, and hearings - enforcement
	50	+	authority - effective date ]
31	51
32	52
33		-	~~SUBJECT: Pharmacy benefit managers~~
	53	+
34	54
35	55		BE IT ENACTED BY THE P EOPLE OF THE STATE OF OKLAHOMA:
36		-
37	56		SECTION 1. AMENDATORY 36 O.S. 2021, Section 6962, as
38	57		amended by Section 2, Chapter 38, O.S.L. 2022 (36 O.S. Supp. 2022,
39	58		Section 6962), is amended to read as follows:
40		-
41	59		Section 6962. A. The Oklahoma Insurance Department Attorney
42	60		General shall review and approve retail pharmacy netwo rk access for
43	61		all pharmacy benefits managers (PBMs) to ensure compliance with
44	62		Section 6961 of this title.
	63	+	B. A PBM, or an agent of a PBM, s hall not:
45	64
46		-	B. A PBM, or an agent of a PBM, s hall not: ENR. H. B. NO. 1843 Page 2
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48	91		1. Cause or knowingly pe rmit the use of advertisement,
49	92		promotion, solicitation, representation, proposal or offer that is
50	93		untrue, deceptive or misleading;
51		-
52	94		2. Charge a pharmacist or phar macy a fee related to the
53	95		adjudication of a claim including without limitation a fee for:
54		-
55	96		a. the submission of a claim,
56		-
57	97		b. enrollment or participation in a retail pharmacy
58	98		network, or
59		-
60	99		c. the development or management of claims processing
61	100		services or claims payment services related to
62	101		participation in a retail pharmacy network;
63		-
64	102		3. Reimburse a pharmacy or pharmacist in the state an amount
65	103		less than the amount that the PBM reimbu rses a pharmacy owned by or
66	104		under common ownership with a PBM for providing the s ame covered
67	105		services. The reimbursement amount paid to the pharmacy shall be
68	106		equal to the reimbursement amount calculated on a per -unit basis
69	107		using the same generic product i dentifier or generic code number
70	108		paid to the PBM-owned or PBM-affiliated pharmacy;
71		-
72	109		4. Deny a provider the opportunity to participate in any
73	110		pharmacy network at preferred participation status if the provider
74	111		is willing to accept the terms and conditions th at the PBM has
75	112		established for other providers as a condition of preferred networ k
76	113		participation status;
77	114
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78	141		5. Deny, limit or terminate a provider's contract based on
79	142		employment status of a ny employee who has an active license to
80	143		dispense, despite probation status, with the State Board of
81	144		Pharmacy;
82		-
83	145		6. Retroactively deny or reduce reimbu rsement for a covered
84	146		service claim after returning a paid claim response as part of the
85	147		adjudication of the claim, unless:
86		-
87	148		a. the original claim was submitted fraudulently, o r
88		-
89	149		b. to correct errors identified in an audit, so long as
90	150		the audit was conducted in compliance with Sections
91		-	356.2 and 356.3 of Title 59 of the Oklahoma Statutes; ENR. H. B. NO. 1843 Page 3
92		-
	151	+	356.2 and 356.3 of Title 59 of the Oklahoma Statutes;
93	152		7. Fail to make any pa yment due to a pharmacy or pharmacist for
94	153		covered services properly r endered in the event a PBM terminates a
95	154		provider from a pharmacy benefits manager network;
96		-
97	155		8. Conduct or practice spread pricing, as defined in Section 1
98	156		of this act, in this state; or
99		-
100	157		9. Charge a pharmacist or pharmacy a fee related to
101	158		participation in a retail pharmacy network including but not limited
102	159		to the following:
	160	+	a. an application fee,
	161	+	b. an enrollment or participation fee,
	162	+	c. a credentialing or re-credentialing fee,
	163	+	d. a change of ownership fee, or
103	164
104		-	a. an application fee,
105		-
106		-	b. an enrollment or participation fee,
107		-
108		-	c. a credentialing or re-credentialing fee,
109		-
110		-	d. a change of ownership fee, or
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111	190
112	191		e. a fee for the development or management of c laims
113	192		processing services or claims payment services .
114		-
115	193		C. The prohibitions under this section shall apply to contracts
116	194		between pharmacy benefits managers and providers for participation
117	195		in retail pharmacy networks.
118		-
119	196		1. A PBM contract shall:
120		-
121	197		a. not restrict, directly or indirectly, any pharmacy
122	198		that dispenses a presc ription drug from informing, or
123	199		penalize such pharmacy for informing, an indivi dual of
124	200		any differential between the individual's out-of-
125	201		pocket cost or coverage with respect to acquisition of
126	202		the drug and the amount an individual would pay to
127	203		purchase the drug directly, and
128		-
129	204		b. ensure that any entity that provides pharmacy benefits
130	205		management services under a contract with any such
131	206		health plan or health insurance coverage does not,
132	207		with respect to such plan or coverage, restrict,
133	208		directly or indirectly, a ph armacy that dispenses a
134	209		prescription drug from informing, or penalize such
135	210		pharmacy for informing, a covered individual of any
136		-	differential between the individual 's out-of-pocket ~~ENR. H. B. NO. 1843 Page 4~~
	211	+	differential between the individual 's out-of-pocket
137	212		cost under the plan or coverage with respect to
138	213		acquisition of the drug and t he amount an individual
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139	241		would pay for acquisition of the drug without using
140	242		any health plan or health insurance coverage.
141		-
142	243		2. A pharmacy benefits manager 's contract with a provider shall
143	244		not prohibit, restrict or limit disclosure of information to the
144	245		Insurance Commissioner Attorney General, law enforcement or state
145	246		and federal governmental officials investigating or examining a
146	247		complaint or conducting a review of a pharmacy benefits manager 's
147	248		compliance with the requirements under the Patient's Right to
148	249		Pharmacy Choice Act.
149		-
150	250		D. A pharmacy benefits manager shall:
151		-
152	251		1. Establish and maintain an elect ronic claim inquiry
153	252		processing system using the National Council for Prescription Drug
154	253		Programs' current standards to communicate information to pharmacies
155	254		submitting claim inquiries ;
156		-
157	255		2. Fully disclose to insurers, self-funded employers, unions or
158	256		other PBM clients the existence of the re spective aggregate
159	257		prescription drug discounts, rebates received from drug
160	258		manufacturers and pharmacy audit recoupments;
161		-
162	259		3. Provide the Insurance Commissioner Attorney General,
163	260		insurers, self-funded employer plans an d unions unrestricted audi t
164	261		rights of and access to the respective PBM pharmaceutical
165	262		manufacturer and provi der contracts, plan utilization data, plan
166	263		pricing data, pharmacy utilization dat a and pharmacy pricing data;
167	264
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168	291		4. Maintain, for no less than three (3) years, documentation of
169	292		all network development activities including but not limited to
170	293		contract negotiations and any denials to providers to join networks.
171	294		This documentation shall be made available to the Commissioner
172	295		Attorney General upon request;
173		-
174	296		5. Report to the Commissioner Attorney General, on a quarterly
175	297		basis for each health insurer payor, on the f ollowing information:
176		-
177	298		a. the aggregate amount of rebates received by t he PBM,
178		-
179	299		b. the aggregate amount of rebates distributed to the
180	300		appropriate health in surer payor,
181		-	ENR. H. B. NO. 1843 Page 5
182	301		c. the aggregate amount of rebates passed on to the
183	302		enrollees of each health insurer payor at the point of
184	303		sale that reduced the applicable deductible,
185	304		copayment, coinsure or other cost sharing amount of
186	305		the enrollee,
187		-
188	306		d. the individual and agg regate amount paid by t he health
189	307		insurer payor to the P BM for pharmacy services
190	308		itemized by pharmacy, d rug product and service
191	309		provided, and
192		-
193	310		e. the individual and aggreg ate amount a PBM paid a
194	311		provider for pharmacy services itemized by pharmacy,
195	312		drug product and service provide d.
196		-
197	313		SECTION 2. AMENDATORY 36 O.S. 2021, Section 6965, is
198	314		amended to read as follows:
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199	341
200	342		Section 6965. A. The Insurance Commissioner Attorney General
201	343		shall have power and authority to examine and investigat e the
202	344		affairs of every pharmacy benefi ts manager (PBM) engaged in pharmacy
203	345		benefits management in this state in order to determine whether such
204	346		entity is in compliance with the Patient 's Right to Pharmacy Choice
205	347		Act.
206		-
207	348		B. All PBM files and records shall be subject to examination by
208	349		the Insurance Commissioner Attorney General or by duly appointed
209	350		designees. The Insurance Commissioner Attorney General, authorized
210	351		employees and examiners shall have access to any of a PBM's files
211	352		and records that may relate to a particular complaint under
212	353		investigation or to an inquiry or examination by the Insurance
213	354		Department Attorney General.
214		-
215	355		C. Every officer, director, employee or agent of the PBM, upon
216	356		receipt of any inquiry from the Commissioner Attorney General shall,
217	357		within twenty (20) days from the date the inquiry is sent , furnish
218	358		the Commissioner Attorney General with an adequate response to the
219	359		inquiry.
220		-
221	360		D. When making an examination under this sectio n, the Insurance
222	361		Commissioner Attorney General may retain subject matter experts,
223	362		attorneys, appraisers, independent actua ries, independent certified
224	363		public accountants or an accounting firm or individual holding a
225	364		permit to practice public accounting, cer tified financial examiners
226		-	or other professionals and specialists as examiners, the cost of ENR. H. B. NO. 1843 Page 6
	365	+	or other professionals and specialists as examiners, the cost of
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227	393		which shall be borne by the PB M that is the subject of the
228	394		examination.
229		-
230	395		SECTION 3. AMENDATORY 36 O.S. 2021, Section 6966.1, as
231	396		amended by Section 3, Chapter 38, O.S.L. 2022 (36 O.S. Supp. 2022,
232	397		Section 6966.1), is amende d to read as follows:
233		-
234	398		Section 6966.1 A. The Insurance Commissioner may censure,
235	399		suspend, revoke or refuse to issue or renew a license of or levy a
236	400		civil penalty against any person licensed under the insurance laws
237	401		of this state for any violation of the Patient's Right to Pharmacy
238	402		Choice Act, Section 6958 et seq. of Title 6 of the Oklahoma Statutes
239	403		this title.
240		-
241	404		B. 1. If the Commissioner Attorney General finds, after notice
242	405		and opportunity for hearing, that a pharmacy benefits manager (PBM)
243	406		violated one or more provisions of the Patient's Right to Pharmacy
244	407		Choice Act, the Pharmacy Audit Integrity Act or the provisions of
245	408		Sections 357 through 360 of Title 59 of the Oklahoma Statues, the
246	409		Attorney General may recommend the PBM may be censured, his or her
247	410		license may be suspended or rev oked and a penalty or remedy
248	411		authorized by this act may be imposed. If the Attorney General
249	412		makes such recommendation, the Commissioner shall take the
250	413		recommended action.
251		-
252	414		2. In addition to or in lieu of any censure, suspension or
253	415		revocation of a license, a PBM may be subject to a civil fine of n ot
254	416		less than One Hundred Dollars ($100.00) and not greater than Ten
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255	444		Thousand Dollars ($10,000.00) for each violation of the provisions
256	445		of the Patient's Right to Pharmacy Choice Act, the Pharmacy Audit
257	446		Integrity Act or the provis ions of Sections 357 through 360 of Title
258	447		59 of the Oklahoma Statues, following notice and an opportunity for
259	448		a hearing.
260		-
261	449		C. Notwithstanding whether the license of a PBM has been
262	450		issued, suspended, revoke d, surrendered or lapsed by operation of
263	451		law, the Commissioner Attorney General is hereby authorized to
264	452		enforce the provisions of the Patient's Right to Pharmacy Cho ice Act
265	453		and impose any penalty or remedy authorized under the act against a
266	454		PBM under investigation for or charg ed with a violation of the
267	455		Patient's Right to Pharmacy Choi ce Act, the Pharmacy Audit Integrity
268	456		Act, the provisions of Se ctions 357 through 360 of Title 59 of the
269	457		Oklahoma Statues or any provision of the insurance laws of this
270	458		state.
271		-	ENR. H. B. NO. 1843 Page 7
272	459		D. Each day that a P BM conducts business in this sta te without
273	460		a license from the Insurance Department shall be deemed a violation
274	461		of the Patient's Right to Pharmacy Choice Act.
275		-
276	462		E. 1. All hearings conducted by the Insurance Department
277	463		office of the Attorney General pursuant to this section shall be
278	464		public and held in accordance with the Administrative Procedures
279	465		Act.
280	466
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281	493		2. Hearings shall be held at the office of the Insurance
282	494		Commissioner Attorney General or any other place the Commissioner
283	495		Attorney General may deem convenient.
284		-
285	496		3. The Commissioner Attorney General, upon written reque st from
286	497		a PBM affected by the hearing, shall cause a full stenographic
287	498		record of the proceedings to be made by a competent court reporter.
288	499		This record shall be at the expense of the PBM.
289		-
290	500		4. The ordinary fees and cost s of the hearing examiner
291	501		appointed pursuant to Section 319 of Title 36 of the Oklahoma
292	502		Statutes this title may be assessed by the hea ring examiner against
293	503		the respondent unless the respondent is the prevailing party.
294		-
295	504		F. Any PBM whose license has been censured, susp ended, revoked
296	505		or denied renewal or who has had a fine levied against him or her
297	506		shall have the right of appeal from the fi nal order of the Insurance
298	507		Commissioner Attorney General, pursuant to Section 318 et seq. of
299	508		Title 75 of the Oklahoma Statutes.
300		-
301	509		G. If the Insurance Commissioner Attorney General determines,
302	510		based upon an investigation of complaints, that a PBM has engaged in
303	511		violations of the provisions of the Patient's Right to Pharmacy
304	512		Choice Act with such frequency as to indicate a general business
305	513		practice, and that the PBM should be subjected to closer supervision
306	514		with respect to those practices, the Commissioner Attorney General
307	515		may require the PBM to file a report at any peri odic interval the
308	516		Commissioner Attorney General deems necessary.
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310	544		SECTION 4. This act shall become effective November 1, 2023.
311		-	ENR. H. B. NO. 1843 Page 8
312		-	Passed the House of Representatives the 21st day of March, 2023.
313		-
314		-
315		-
316		-
317		-	Presiding Officer of the House
318		-	of Representatives
319		-
320		-
321		-	Passed the Senate the 25th day of April, 2023.
322		-
323		-
324		-
325		-
326		-	Presiding Officer of the Senate
327		-
328		-
329		-	OFFICE OF THE GOVERNOR
330		-	Received by the Office of the Governor this ____________________
331		-	day of ___________________, 20_______, at _______ o'clock _______ M.
332		-	By: _________________________________
333		-	Approved by the Governor of the State of Oklahoma this _________
334		-	day of ___________________, 20_______, at _______ o'clock _______ M.
335		-
336		-
337		-	_________________________________
338		-	Governor of the State of Oklahoma
339		-
340		-	OFFICE OF THE SECRETARY OF STATE
341		-	Received by the Office of the Secretary of State this __________
342		-	day of ___________________, 20_______, at _______ o'clock _______ M.
343		-	By: _________________________________
344		-
	545	+	COMMITTEE REPORT BY: COMMITTEE ON APPROPRIATIONS
	546	+	April 12, 2023 - DO PASS AS AMENDED