| 3 | | - | SENATE FLOOR VERSION - SB879 SFLR Page 1 |
|---|
| 4 | | - | (Bold face denotes Co mmittee Amendments) 1 |
|---|
| 5 | | - | 2 |
|---|
| 6 | | - | 3 |
|---|
| 7 | | - | 4 |
|---|
| 8 | | - | 5 |
|---|
| 9 | | - | 6 |
|---|
| 10 | | - | 7 |
|---|
| 11 | | - | 8 |
|---|
| 12 | | - | 9 |
|---|
| 13 | | - | 10 |
|---|
| 14 | | - | 11 |
|---|
| 15 | | - | 12 |
|---|
| 16 | | - | 13 |
|---|
| 17 | | - | 14 |
|---|
| 18 | | - | 15 |
|---|
| 19 | | - | 16 |
|---|
| 20 | | - | 17 |
|---|
| 21 | | - | 18 |
|---|
| 22 | | - | 19 |
|---|
| 23 | | - | 20 |
|---|
| 24 | | - | 21 |
|---|
| 25 | | - | 22 |
|---|
| 26 | | - | 23 |
|---|
| 27 | | - | 24 |
|---|
| 28 | | - | |
|---|
| 29 | | - | SENATE FLOOR VERSION |
|---|
| 30 | | - | February 14, 2023 |
|---|
| 31 | | - | AS AMENDED |
|---|
| 32 | | - | |
|---|
| 33 | | - | SENATE BILL NO. 879 By: Montgomery |
|---|
| 34 | | - | |
|---|
| 35 | | - | |
|---|
| 36 | | - | |
|---|
| 37 | | - | |
|---|
| 38 | | - | |
|---|
| 39 | | - | [ pharmacy benefits mana gers - compliance review - |
|---|
| 40 | | - | contractual provisions - publication - |
|---|
| 41 | | - | confidentiality - compliance measures - decisions - |
|---|
| 42 | | - | committee members - definitions - licensure - |
|---|
| 43 | | - | applications - codification - effective date ] |
|---|
| 44 | | - | |
|---|
| 3 | + | |
|---|
| 4 | + | Req. No. 712 Page 1 1 |
|---|
| 5 | + | 2 |
|---|
| 6 | + | 3 |
|---|
| 7 | + | 4 |
|---|
| 8 | + | 5 |
|---|
| 9 | + | 6 |
|---|
| 10 | + | 7 |
|---|
| 11 | + | 8 |
|---|
| 12 | + | 9 |
|---|
| 13 | + | 10 |
|---|
| 14 | + | 11 |
|---|
| 15 | + | 12 |
|---|
| 16 | + | 13 |
|---|
| 17 | + | 14 |
|---|
| 18 | + | 15 |
|---|
| 19 | + | 16 |
|---|
| 20 | + | 17 |
|---|
| 21 | + | 18 |
|---|
| 22 | + | 19 |
|---|
| 23 | + | 20 |
|---|
| 24 | + | 21 |
|---|
| 25 | + | 22 |
|---|
| 26 | + | 23 |
|---|
| 27 | + | 24 |
|---|
| 28 | + | 1 |
|---|
| 29 | + | 2 |
|---|
| 30 | + | 3 |
|---|
| 31 | + | 4 |
|---|
| 32 | + | 5 |
|---|
| 33 | + | 6 |
|---|
| 34 | + | 7 |
|---|
| 35 | + | 8 |
|---|
| 36 | + | 9 |
|---|
| 37 | + | 10 |
|---|
| 38 | + | 11 |
|---|
| 39 | + | 12 |
|---|
| 40 | + | 13 |
|---|
| 41 | + | 14 |
|---|
| 42 | + | 15 |
|---|
| 43 | + | 16 |
|---|
| 44 | + | 17 |
|---|
| 45 | + | 18 |
|---|
| 46 | + | 19 |
|---|
| 47 | + | 20 |
|---|
| 48 | + | 21 |
|---|
| 49 | + | 22 |
|---|
| 50 | + | 23 |
|---|
| 51 | + | 24 |
|---|
| 52 | + | |
|---|
| 53 | + | STATE OF OKLAHOMA |
|---|
| 54 | + | |
|---|
| 55 | + | 1st Session of the 59th Legislature (2023) |
|---|
| 56 | + | |
|---|
| 57 | + | SENATE BILL 879 By: Montgomery |
|---|
| 58 | + | |
|---|
| 59 | + | |
|---|
| 60 | + | |
|---|
| 61 | + | |
|---|
| 62 | + | |
|---|
| 63 | + | AS INTRODUCED |
|---|
| 64 | + | |
|---|
| 65 | + | An Act relating to pharmacy benefits mana gers; |
|---|
| 66 | + | amending 36 O.S. 2021, Sections 6960, as amended by |
|---|
| 67 | + | Section 1, Chapter 38, O.S.L. 2022 and 6962, as |
|---|
| 68 | + | amended by Section 2, Chapter 38, O.S.L. 2022 (36 |
|---|
| 69 | + | O.S. Supp. 2022, Section s 6960 and 6962), which |
|---|
| 70 | + | relate to definitions and compliance review; adding |
|---|
| 71 | + | and modifying definitions; prohibiting ce rtain |
|---|
| 72 | + | contractual provisions; requiring publication of |
|---|
| 73 | + | certain formulary information; requiring pharmacy |
|---|
| 74 | + | benefits managers to provide certain reports; |
|---|
| 75 | + | requiring publication of certain monies received by |
|---|
| 76 | + | pharmacy benefits man agers; providing confidentiality |
|---|
| 77 | + | of certain records; establishing compliance measures |
|---|
| 78 | + | for defined cost sharing ; amending 36 O.S. 2021, |
|---|
| 79 | + | Section 6964, which relates to drug formulary |
|---|
| 80 | + | decisions; modifying requirements and duties of |
|---|
| 81 | + | pharmacy and therapeutics c ommittee members; amending |
|---|
| 82 | + | 51 O.S. 2021, Section 24A.3, as last amended by |
|---|
| 83 | + | Section 1, Chapter 402, O.S.L. 2022 (51 O.S. Supp. |
|---|
| 84 | + | 2022, Section 24A.3) , which relates to definitions; |
|---|
| 85 | + | modifying definition; amending 59 O.S. 2021, Sections |
|---|
| 86 | + | 357 and 358, which relate to definitions and |
|---|
| 87 | + | licensure; modifying definitions; modifying |
|---|
| 88 | + | requirements for certain applications; updating |
|---|
| 89 | + | statutory references; providing for codification; and |
|---|
| 90 | + | providing an effective date. |
|---|
| 50 | 147 | | SECTION 1. AMENDATORY 36 O.S. 2021, Section 6960, a s |
|---|
| 51 | 148 | | amended by Section 1, Chapter 38, O.S.L. 2022 (36 O.S. Supp. 2022, |
|---|
| 52 | 149 | | Section 6960), is amended to read as follows: |
|---|
| 53 | 150 | | Section 6960. For purposes of the P atient’s Right to Pharmacy |
|---|
| 54 | 151 | | Choice Act: |
|---|
| 55 | 152 | | 1. “Aggregate retained rebate percentage” means the percentage |
|---|
| 56 | 153 | | of all rebates received by a PBM from all pharmaceutical |
|---|
| 57 | 154 | | manufacturers which is not passed on to the PBM’s health plan or |
|---|
| 58 | 155 | | health insurer clients. The aggregate retained rebate percentage |
|---|
| 59 | 156 | | shall be expressed without disclosing any identifying information |
|---|
| 60 | 157 | | regarding any health plan, prescription drug, or therapeutic class, |
|---|
| 61 | 158 | | and shall be calculated by dividing: |
|---|
| 89 | 159 | | a. the aggregate dollar amount of all rebates that the |
|---|
| 90 | 160 | | PBM received during the prior calendar year from all |
|---|
| 91 | 161 | | pharmaceutical manufacturers that did not pass through |
|---|
| 92 | 162 | | to the pharmacy benefits manager’s health plan or |
|---|
| 93 | 163 | | health insurer clients, by |
|---|
| 94 | 164 | | b. the aggregate dollar amount of all rebates that the |
|---|
| 95 | 165 | | pharmacy benefits manager received during the prior |
|---|
| 96 | 166 | | calendar year from all pharmaceutical manufacturers; |
|---|
| 97 | 167 | | 2. “Defined cost sharing” means a deductible payment or |
|---|
| 98 | 168 | | coinsurance amount imposed on an enrollee for a covered prescription |
|---|
| 99 | 169 | | drug under the enrollee’s health plan; |
|---|
| 100 | 221 | | 3. “Formulary” means a list of prescription drugs, any |
|---|
| 101 | 222 | | prescription drug accompanying tiering, and other coverage |
|---|
| 102 | 223 | | information that has been developed by a health insurer or its |
|---|
| 103 | 224 | | designee that is referenced in determining applicable coverage and |
|---|
| 104 | 225 | | benefit levels; |
|---|
| 105 | 226 | | 4. “Generic equivalent” means a drug that is designated as |
|---|
| 106 | 227 | | therapeutically equivalent by the United States Food and Dru g |
|---|
| 107 | 228 | | Administration’s Approved Drug Products wi th Therapeutic Equivalence |
|---|
| 108 | 229 | | Evaluations; provided, however, a drug shall not be considered a |
|---|
| 109 | 230 | | generic equivalent until the drug becomes nationally available; |
|---|
| 110 | 231 | | 5. “Health insurer” or “insurer” means any corporation, |
|---|
| 111 | 232 | | association, benefit society , exchange, partnership, or individual, |
|---|
| 139 | 233 | | or other legal entity licensed by the Oklahoma Insurance Code to |
|---|
| 140 | 234 | | provide health benefit plans; |
|---|
| 141 | 235 | | 6. “Health insurer administrative service fees” means fees or |
|---|
| 142 | 236 | | payments from a health insurer or its designee to, or otherwise |
|---|
| 143 | 237 | | retained by, a PBM or its design ee pursuant to a contract between a |
|---|
| 144 | 238 | | PBM or affiliate and the health insurer or its designee in |
|---|
| 145 | 239 | | connection with the PBM’s managing or administering the pharmacy |
|---|
| 146 | 240 | | benefit and administering, invoicing, alloc ating, and collecting |
|---|
| 147 | 241 | | rebates; |
|---|
| 148 | 242 | | 7. “Health benefit plan” means a policy, contract, |
|---|
| 149 | 243 | | certification, or agreement offered or issued by a health insurer to |
|---|
| 150 | 295 | | provide, deliver, arrange for, pay for, or reimburse any of the |
|---|
| 151 | 296 | | costs of health services; |
|---|
| 152 | 297 | | 2. 8. “Health insurer payor” means a health insurance company, |
|---|
| 153 | 298 | | health maintenance organization, union, h ospital and medical |
|---|
| 154 | 299 | | services organization or any entity providing or admin istering a |
|---|
| 155 | 300 | | self-funded health benefit plan; |
|---|
| 156 | 301 | | 3. 9. “Mail-order pharmacy” means a pharmacy licensed by this |
|---|
| 157 | 302 | | state that primarily dispenses and delivers covere d drugs via by |
|---|
| 158 | 303 | | common carrier; |
|---|
| 159 | 304 | | 10. “Pharmaceutical manufacturing administrative fees” means |
|---|
| 160 | 305 | | fees or payments from pharmaceutical manufacturers to, or otherwise |
|---|
| 161 | 306 | | retained by, a pharmacy benefits manager (PBM) or its designe e |
|---|
| 162 | 307 | | pursuant to a contract between a PBM or affiliate and the |
|---|
| 190 | 308 | | manufacturer in connection with the PBM’s administering, invoicing, |
|---|
| 191 | 309 | | allocating, and collecting rebates; |
|---|
| 192 | 310 | | 11. “Pharmacy” or “provider” means a pharmacy as defined |
|---|
| 193 | 311 | | pursuant to Section 353.1 of Title 59 of the Oklah oma Statutes; |
|---|
| 194 | 312 | | 4. 12. “Pharmacy benefits manager ” or “PBM” means a person |
|---|
| 195 | 313 | | that, either directly or through an intermediary, performs pharmacy |
|---|
| 196 | 314 | | benefits management, as defined by paragraph 6 of Section 357 of |
|---|
| 197 | 315 | | Title 59 of the Oklah oma Statutes, and any other person acting for |
|---|
| 198 | 316 | | such person under a contractual or employm ent relationship in the |
|---|
| 199 | 317 | | performance of pharmacy benefits management for a managed -care |
|---|
| 200 | 318 | | company, nonprofit hospi tal, medical service organizatio n, insurance |
|---|
| 201 | 370 | | company, third-party payor or a health program administered by a |
|---|
| 202 | 371 | | department of this state; |
|---|
| 203 | 372 | | 13. “Price protection rebat e” means a negotiated price |
|---|
| 204 | 373 | | concession that accrues directly o r indirectly to the health insurer |
|---|
| 205 | 374 | | or other party on behalf of the health insurer in the event of an |
|---|
| 206 | 375 | | increase in the wholesale acquisition cost of a dru g above a |
|---|
| 207 | 376 | | specified cost threshold; |
|---|
| 208 | 377 | | 5. “Provider” means a pharmacy, as defined i n Section 353.1 of |
|---|
| 209 | 378 | | Title 59 of the Oklahoma Statutes o r an agent or representative of a |
|---|
| 210 | 379 | | pharmacy; |
|---|
| 211 | 380 | | 14. “Rebates” means: |
|---|
| 212 | 381 | | a. negotiated price concessi ons including but not limited |
|---|
| 213 | 382 | | to base price concessio ns, whether described as a |
|---|
| 241 | 383 | | rebate or otherwise, and reasonable estimates of any |
|---|
| 242 | 384 | | price protection rebates and performance-based price |
|---|
| 243 | 385 | | concessions that may accrue directly or indirectly to |
|---|
| 244 | 386 | | the PBM during the coverage year from a manufacturer, |
|---|
| 245 | 387 | | dispensing pharmacy, or other party in connection with |
|---|
| 246 | 388 | | the dispensing or administration of a prescription |
|---|
| 247 | 389 | | drug, and |
|---|
| 248 | 390 | | b. reasonable estimates of any price concessions, fees, |
|---|
| 249 | 391 | | and other administrative costs that are passed |
|---|
| 250 | 392 | | through, or are reasonably anticipated to be passed |
|---|
| 251 | 444 | | through, to the PBM and serve to reduce the PBM’s |
|---|
| 252 | 445 | | liabilities for a prescription drug; |
|---|
| 253 | 446 | | 6. 15. “Retail pharmacy network” means retail pharmacy |
|---|
| 254 | 447 | | providers contracted with a PBM in which the pharmacy primari ly |
|---|
| 255 | 448 | | fills and sells prescriptions via from a retail, storefront |
|---|
| 256 | 449 | | location; |
|---|
| 257 | 450 | | 7. 16. “Rural service area” means a five-digit ZIP code in |
|---|
| 258 | 451 | | which the population density is less than one thousand (1,000 ) |
|---|
| 259 | 452 | | individuals per square mile; |
|---|
| 260 | 453 | | 8. 17. “Spread pricing” means a prescription drug pricing model |
|---|
| 261 | 454 | | utilized by a pharmacy benefits man ager in which the PBM charges a |
|---|
| 262 | 455 | | health benefit plan a contract ed price for prescription drug s that |
|---|
| 263 | 456 | | differs from the amount th e PBM directly or indirectly pays the |
|---|
| 264 | 457 | | pharmacy or pharmacist for pr oviding pharmacy services; |
|---|
| 292 | 458 | | 9. 18. “Suburban service area ” means a five-digit ZIP code in |
|---|
| 293 | 459 | | which the population density is betw een one thousand (1,000) and |
|---|
| 294 | 460 | | three thousand (3,000) individuals per square mile; and |
|---|
| 295 | 461 | | 10. 19. “Urban service area” means a five-digit ZIP code in |
|---|
| 296 | 462 | | which the population density is greater than thre e thousand (3,000) |
|---|
| 297 | 463 | | individuals per square mile. |
|---|
| 298 | 464 | | SECTION 2. AMENDATORY 36 O.S. 2021, Section 6962, a s |
|---|
| 299 | 465 | | amended by Section 2, Chapter 38, O.S.L. 2022 (36 O.S. Supp. 2022, |
|---|
| 300 | 466 | | Section 6962), is amended to read as follows: |
|---|
| 301 | 518 | | Section 6962. A. The Oklahoma Insurance Department shall |
|---|
| 302 | 519 | | review and approve retail pharmacy network acces s for all pharmacy |
|---|
| 303 | 520 | | benefits managers (PBMs) to ensure compliance with Section 6961 of |
|---|
| 304 | 521 | | this title. |
|---|
| 305 | 522 | | B. A PBM, or an agent of a PBM, s hall not: |
|---|
| 306 | 523 | | 1. Cause or knowingly permit the use of advertisement, |
|---|
| 307 | 524 | | promotion, solicitation, rep resentation, proposal or offer that is |
|---|
| 308 | 525 | | untrue, deceptive or misl eading; |
|---|
| 309 | 526 | | 2. Charge a pharmacist or pharmacy a fee related to the |
|---|
| 310 | 527 | | adjudication of a claim including without limitation a fee for: |
|---|
| 311 | 528 | | a. the submission of a claim, |
|---|
| 312 | 529 | | b. enrollment or participation in a retail pharmacy |
|---|
| 313 | 530 | | network, or |
|---|
| 341 | 531 | | c. the development or management of claims processing |
|---|
| 342 | 532 | | services or claims payment services related to |
|---|
| 343 | 533 | | participation in a retail p harmacy network; |
|---|
| 344 | 534 | | 3. Reimburse a pharmacy or pharmacist in the state an am ount |
|---|
| 345 | 535 | | less than the amount that the PBM reimburses a p harmacy owned by or |
|---|
| 346 | 536 | | under common ownership with a PBM for providing the same covered |
|---|
| 347 | 537 | | services. The reimbursement amount paid to the pharmacy shall be |
|---|
| 348 | 538 | | equal to the reimbursement amount calculated on a pe r-unit basis |
|---|
| 349 | 539 | | using the same generic product identifie r or generic code number |
|---|
| 350 | 540 | | paid to the PBM-owned or PBM-affiliated pharmacy; |
|---|
| 351 | 592 | | 4. Deny a provider the opportunity to participate i n any |
|---|
| 352 | 593 | | pharmacy network at preferred participation status if the provider |
|---|
| 353 | 594 | | is willing to accept the t erms and conditions that the P BM has |
|---|
| 354 | 595 | | established for other providers as a condition of preferred network |
|---|
| 355 | 596 | | participation status; |
|---|
| 356 | 597 | | 5. Deny, limit or terminate a provider’s contract based on |
|---|
| 357 | 598 | | employment status of any employee who has an a ctive license to |
|---|
| 358 | 599 | | dispense, despite probation status, with the State Board of |
|---|
| 359 | 600 | | Pharmacy; |
|---|
| 360 | 601 | | 6. Retroactively deny or reduce reimbursement for a covered |
|---|
| 361 | 602 | | service claim after ret urning a paid claim response as part of the |
|---|
| 362 | 603 | | adjudication of the claim, unless: |
|---|
| 363 | 604 | | a. the original claim was sub mitted fraudulently, or |
|---|
| 391 | 605 | | b. to correct errors identified in an au dit, so long as |
|---|
| 392 | 606 | | the audit was conducted in compliance with Sections |
|---|
| 393 | 607 | | 356.2 and 356.3 of Title 59 of the Oklahoma Statutes; |
|---|
| 394 | 608 | | 7. Fail to make any payment due to a pharmacy or pharmacist for |
|---|
| 395 | 609 | | covered services properly re ndered in the event a PBM terminates a |
|---|
| 396 | 610 | | provider from a pharmacy benefits manager network ; |
|---|
| 397 | 611 | | 8. Conduct or practice spread pricing , as defined in Section 1 |
|---|
| 398 | 612 | | of this act 6960 of this title, in this state; or |
|---|
| 399 | 613 | | 9. Charge a pharmacist or pharmacy a fee related to |
|---|
| 400 | 614 | | participation in a retail ph armacy network including but no t limited |
|---|
| 401 | 615 | | to the following: |
|---|
| 402 | 667 | | a. an application fee, |
|---|
| 403 | 668 | | b. an enrollment or participation fee, |
|---|
| 404 | 669 | | c. a credentialing or re-credentialing fee, |
|---|
| 405 | 670 | | d. a change of ownership fee, or |
|---|
| 406 | 671 | | e. a fee for the development or management of claims |
|---|
| 407 | 672 | | processing services or claims paymen t services. |
|---|
| 408 | 673 | | C. The prohibitions under this sec tion shall apply to contracts |
|---|
| 409 | 674 | | between pharmacy benefits managers and providers for participation |
|---|
| 410 | 675 | | in retail pharmacy networks. |
|---|
| 411 | 676 | | 1. A PBM contract shall: |
|---|
| 412 | 677 | | a. not restrict, directly or indirectly, any pharmacy |
|---|
| 413 | 678 | | that dispenses a prescription drug from informing, or |
|---|
| 414 | 679 | | penalize such pharmacy for informing, an indivi dual of |
|---|
| 442 | 680 | | any differential between the individual’s out-of- |
|---|
| 443 | 681 | | pocket cost or coverage with respect to acquisition of |
|---|
| 444 | 682 | | the drug and the amount an individual would pa y to |
|---|
| 445 | 683 | | purchase the drug directly, and |
|---|
| 446 | 684 | | b. ensure that any entity that provides pharmacy benefits |
|---|
| 447 | 685 | | management services under a contract with any such |
|---|
| 448 | 686 | | health plan or health insurance coverage does not, |
|---|
| 449 | 687 | | with respect to such plan or coverage, restrict, |
|---|
| 450 | 688 | | directly or indirectly, a pharmacy that dispenses a |
|---|
| 451 | 689 | | prescription drug from informing, o r penalize such |
|---|
| 452 | 690 | | pharmacy for informing, a covered indi vidual of any |
|---|
| 453 | 742 | | differential between the individual’s out-of-pocket |
|---|
| 454 | 743 | | cost under the plan or cover age with respect to |
|---|
| 455 | 744 | | acquisition of the drug and the amount an individual |
|---|
| 456 | 745 | | would pay for acquisition of the dr ug without using |
|---|
| 457 | 746 | | any health plan or health insurance c overage, |
|---|
| 458 | 747 | | c. not prohibit from or penalize for a pharmacy or |
|---|
| 459 | 748 | | pharmacist disclosing to an individual information |
|---|
| 460 | 749 | | regarding the existence and clinical efficacy of a |
|---|
| 461 | 750 | | generic equivalent that would be less expensive to the |
|---|
| 462 | 751 | | enrollee under his or her health plan p rescription |
|---|
| 463 | 752 | | drug benefit or outside his or her health plan |
|---|
| 464 | 753 | | prescription drug benefit, without requesting any |
|---|
| 492 | 754 | | health plan reimbursement, than the drug that was |
|---|
| 493 | 755 | | originally prescribed, and |
|---|
| 494 | 756 | | d. not prohibit from or penalize for a pharmacy or |
|---|
| 495 | 757 | | pharmacist selling to an individual, instead of a |
|---|
| 496 | 758 | | particular prescribed drug, a therapeutically |
|---|
| 497 | 759 | | equivalent drug that would be less expensive to the |
|---|
| 498 | 760 | | enrollee under his or her health plan prescription |
|---|
| 499 | 761 | | drug benefit or outside his or her health plan |
|---|
| 500 | 762 | | prescription drug benefit , without requesting any |
|---|
| 501 | 763 | | health plan reimbursement, than the drug that was |
|---|
| 502 | 764 | | originally prescribed. |
|---|
| 503 | 816 | | 2. A pharmacy benefits manager ’s contract with a provider shall |
|---|
| 504 | 817 | | not prohibit, restrict or limit disclosure of information to the |
|---|
| 505 | 818 | | Insurance Commissioner, law enforc ement or state and federal |
|---|
| 506 | 819 | | governmental officials investigating or examining a complaint or |
|---|
| 507 | 820 | | conducting a review of a pharmacy benefits manager’s compliance with |
|---|
| 508 | 821 | | the requirements under the Patient’s Right to Pharmacy Choice Act. |
|---|
| 509 | 822 | | 3. For each of the PBM’s contracts or other relationships with |
|---|
| 510 | 823 | | a health plan, a PBM shall publish on an easily accessible website |
|---|
| 511 | 824 | | the health plan formulary and timely notification of formulary |
|---|
| 512 | 825 | | changes and product exclusions. |
|---|
| 513 | 826 | | D. A pharmacy benefits manager shall : |
|---|
| 514 | 827 | | 1. Establish and maintain an electronic claim inquiry |
|---|
| 515 | 828 | | processing system using t he National Council for Prescript ion Drug |
|---|
| 543 | 829 | | Programs’ current standards to communicate information to pharmacies |
|---|
| 544 | 830 | | submitting claim inquiries ; |
|---|
| 545 | 831 | | 2. Fully disclose to insurers, self -funded employers, unions or |
|---|
| 546 | 832 | | other PBM clients the existence of the respective ag gregate |
|---|
| 547 | 833 | | prescription drug discoun ts, rebates received from drug |
|---|
| 548 | 834 | | manufacturers and pharmacy audit recoupments; |
|---|
| 549 | 835 | | 3. Provide the Insurance Commissioner, insurers, self -funded |
|---|
| 550 | 836 | | employer plans and unions unrestricted audit rights of and access to |
|---|
| 551 | 837 | | the respective PBM pharmaceutical manufacturer a nd provider |
|---|
| 552 | 838 | | contracts, plan utilization data, plan pricing data, pharmacy |
|---|
| 553 | 839 | | utilization data and pharmacy pricing data; |
|---|
| 554 | 891 | | 4. Maintain, for no less than three (3) years, documentation of |
|---|
| 555 | 892 | | all network development activities inclu ding but not limited to |
|---|
| 556 | 893 | | contract negotiations and any denials to providers to join networks. |
|---|
| 557 | 894 | | This documentation shall be made available to the Commissioner upon |
|---|
| 558 | 895 | | request; and |
|---|
| 559 | 896 | | 5. Report to the Commissioner, on a quarterly basis for each |
|---|
| 560 | 897 | | health insurer payor, on the following information: |
|---|
| 561 | 898 | | a. the aggregate amount of rebates received by the PBM, |
|---|
| 562 | 899 | | b. the aggregate amount of rebates distributed to the |
|---|
| 563 | 900 | | appropriate health insurer payor, |
|---|
| 564 | 901 | | c. the aggregate amount of rebates passed on to the |
|---|
| 565 | 902 | | enrollees of each health in surer payor at the point of |
|---|
| 566 | 903 | | sale that reduced the applicable deducti ble, |
|---|
| 603 | 964 | | SECTION 3. NEW LAW A new section of law to be codified |
|---|
| 604 | 965 | | in the Oklahoma Statutes as Section 6962.1 of Title 36, unless there |
|---|
| 605 | 966 | | is created a duplication in numbering, reads as follows: |
|---|
| 606 | 967 | | A. Beginning on November 1, 2023, and on an annual basis |
|---|
| 607 | 968 | | thereafter, a pharmacy benefits manager (PBM) shall provide the |
|---|
| 608 | 969 | | Insurance Department with a report containing the following |
|---|
| 609 | 970 | | information from the prior calendar year as it pertains to pharmacy |
|---|
| 610 | 971 | | benefits provided by health insurers to enrollees in the stat e: |
|---|
| 611 | 972 | | 1. The aggregate dollar amount of all rebates that the PBM |
|---|
| 612 | 973 | | received from all pharmaceutical manufacturers; |
|---|
| 613 | 974 | | 2. The aggregate dollar amount of all administrative fees that |
|---|
| 614 | 975 | | the PBM received; |
|---|
| 615 | 976 | | 3. The aggregate dollar amount of all issuer administrative |
|---|
| 616 | 977 | | service fees that the PBM received; |
|---|
| 644 | 978 | | 4. The aggregate dollar amount of all rebates that the PBM |
|---|
| 645 | 979 | | received from all pharmaceutical manufacturers and did not pass |
|---|
| 646 | 980 | | through to health plans or health insurers; |
|---|
| 647 | 981 | | 5. The aggregate dollar amount of all administrative fees that |
|---|
| 648 | 982 | | the PBM received from all pharmaceutical manufacturers and did not |
|---|
| 649 | 983 | | pass through to health plans or health insurers; |
|---|
| 650 | 984 | | 6. The aggregate retained rebate percentage; and |
|---|
| 651 | 985 | | 7. The highest aggregate retained rebate perc entage, the lowest |
|---|
| 652 | 986 | | aggregate retained rebate percentage, and the mean aggregate |
|---|
| 653 | 987 | | retained rebate percentage across all of the pharmacy benefits |
|---|
| 654 | 1039 | | manager’s contractual or other relationships with all hea lth benefit |
|---|
| 655 | 1040 | | plans or health insurers . |
|---|
| 656 | 1041 | | B. The Department shall publi sh in a timely manner the |
|---|
| 657 | 1042 | | information that it receives under subsection A of this section on a |
|---|
| 658 | 1043 | | publicly available website, provided that such information shall be |
|---|
| 659 | 1044 | | made available in a form that does not disclose the identity of a |
|---|
| 660 | 1045 | | specific health plan or the identity of a specific manufacturer, the |
|---|
| 661 | 1046 | | prices charged for specific drugs or classe s of drugs, or the amount |
|---|
| 662 | 1047 | | of any rebates provided for specific drugs or classes of drugs. |
|---|
| 663 | 1048 | | C. The PBM and the Department shall not publish or otherwise |
|---|
| 664 | 1049 | | disclose any information that would disclose the identity of a |
|---|
| 665 | 1050 | | specific health plan, any prices charged for a specific drug or |
|---|
| 666 | 1051 | | class of drugs, the amount of any rebates provided for a specific |
|---|
| 667 | 1052 | | drug or class of drugs, the manufacturer, or information that would |
|---|
| 695 | 1053 | | otherwise have the potential to compromise the financ ial, |
|---|
| 696 | 1054 | | competitive, or proprietary nature of the information. The |
|---|
| 697 | 1055 | | information shall be protected from direct or indirect disclosure as |
|---|
| 698 | 1056 | | confidential and proprietary information and shall not be deemed a |
|---|
| 699 | 1057 | | public record as defined pursuant to Section 24A.3 of Title 51 of |
|---|
| 700 | 1058 | | the Oklahoma Statutes. A PBM shall impose the confidentiality |
|---|
| 701 | 1059 | | protections of this section on any vendor or downstream third party |
|---|
| 702 | 1060 | | that performs health care or administrative services o n behalf of |
|---|
| 703 | 1061 | | the PBM that may receive or have access to rebate information. |
|---|
| 704 | 1113 | | SECTION 4. NEW LAW A new section of law to be codified |
|---|
| 705 | 1114 | | in the Oklahoma Statutes as Section 6962.2 of Title 36, unless there |
|---|
| 706 | 1115 | | is created a duplication in numbering, reads as follows: |
|---|
| 707 | 1116 | | A. An enrollee’s defined cost sharing , as defined pursuant to |
|---|
| 708 | 1117 | | Section 6960 of Title 36 of the Oklahoma Statutes , for each |
|---|
| 709 | 1118 | | prescription drug shall be calculated at the point of sale based on |
|---|
| 710 | 1119 | | a price that is reduced by an amount equal to one hundred percent |
|---|
| 711 | 1120 | | (100%) of all rebates received, or to b e received, in connect ion |
|---|
| 712 | 1121 | | with the dispensing or administration of the prescription drug. |
|---|
| 713 | 1122 | | B. For any violation of this section, the Insurance |
|---|
| 714 | 1123 | | Commissioner may subject a pharmacy benefits manager (PBM) to an |
|---|
| 715 | 1124 | | administrative penalty not less than One Hundred Dollars ($100.00), |
|---|
| 716 | 1125 | | nor more than Five Thousand Dollars ($5,000.00) for each occurrence. |
|---|
| 717 | 1126 | | Such administrative pena lty may be enforced in the same manner in |
|---|
| 718 | 1127 | | which civil judgments may be enforced. |
|---|
| 746 | 1128 | | C. Nothing in this section shall preclude a PBM from decreasing |
|---|
| 747 | 1129 | | an enrollee’s defined cost sharing by an amount greater than that |
|---|
| 748 | 1130 | | required under subsection A of this section. |
|---|
| 749 | 1131 | | D. In complying with the pr ovisions of this section, a PBM or |
|---|
| 750 | 1132 | | its agents shall not publish or otherwi se disclose information |
|---|
| 751 | 1133 | | regarding the actual amount of rebate s a PBM receives on a product |
|---|
| 752 | 1134 | | or therapeutic class of products, manufacturer, or pharmacy-specific |
|---|
| 753 | 1135 | | basis. Such information is protected as a trade secret, is not a |
|---|
| 754 | 1136 | | public record as defined pursuant to Section 24A.3 of Title 51 of |
|---|
| 755 | 1188 | | the Oklahoma Statutes, and shall not be disclosed directly or |
|---|
| 756 | 1189 | | indirectly, or in a manner that would allow for the identification |
|---|
| 757 | 1190 | | of an individual product, therapeutic class of products, or |
|---|
| 758 | 1191 | | manufacturer, or in a manner that would have the potential to |
|---|
| 759 | 1192 | | compromise the financial, competitive, or proprietary nature of the |
|---|
| 760 | 1193 | | information. A PBM shall impose the confidentiality protections of |
|---|
| 761 | 1194 | | this section on any vendor or downstream third party that performs |
|---|
| 762 | 1195 | | health care or administrative services on behalf of the insur er that |
|---|
| 763 | 1196 | | may receive or have access to rebate information. |
|---|
| 764 | 1197 | | SECTION 5. NEW LAW A new section of law to be codified |
|---|
| 765 | 1198 | | in the Oklahoma Statutes as Section 6962.3 of Title 36, unless there |
|---|
| 766 | 1199 | | is created a duplication in numb ering, reads as follows: |
|---|
| 767 | 1200 | | A. An enrollee’s defined cost sharing, as defined pursuant to |
|---|
| 768 | 1201 | | Section 6960 of Title 36 of the Oklahoma S tatutes, for each |
|---|
| 769 | 1202 | | prescription drug shall be calculated at the point of sale based on |
|---|
| 797 | 1203 | | a price that is reduced by an amount equal to one hundred percent |
|---|
| 798 | 1204 | | (100%) of all rebates received or to be received in connection with |
|---|
| 799 | 1205 | | the dispensing or administration of the prescription drug. |
|---|
| 800 | 1206 | | B. For any violation of this section, the Insurance |
|---|
| 801 | 1207 | | Commissioner may subject an insurer to an administrative penalty not |
|---|
| 802 | 1208 | | less than One Hundred Dollars ($100.00), nor more than Five Thousand |
|---|
| 803 | 1209 | | Dollars ($5,000.00) for each occurrence. Such administrative |
|---|
| 804 | 1210 | | penalty may be enforced in the same manner in which civil judgments |
|---|
| 805 | 1211 | | may be enforced. |
|---|
| 806 | 1263 | | C. Nothing in this section shall preclude an insurer from |
|---|
| 807 | 1264 | | decreasing an enroll ee’s defined cost sharing by an a mount greater |
|---|
| 808 | 1265 | | than that required under subsection A of this section. |
|---|
| 809 | 1266 | | D. An insurer or its agents shall not publish or otherwise |
|---|
| 810 | 1267 | | disclose information regarding the act ual amount of rebates an |
|---|
| 811 | 1268 | | insurer receives on a product o r therapeutic class of produc ts, |
|---|
| 812 | 1269 | | manufacturer, or pharmacy-specific basis. Such information is |
|---|
| 813 | 1270 | | protected as a trade secret, is not a public record pursuant to |
|---|
| 814 | 1271 | | Section 24A.3 of Title 51 of the Oklahom a Statutes, and shall not be |
|---|
| 815 | 1272 | | disclosed directly or indir ectly or in a manner that woul d allow for |
|---|
| 816 | 1273 | | the identification of an individual product, therapeutic class o f |
|---|
| 817 | 1274 | | products, or manufacturer, or in a manner that would have the |
|---|
| 818 | 1275 | | potential to compromise the fi nancial, competitive, or proprietary |
|---|
| 819 | 1276 | | nature of the information. The confidentiality pr otections provided |
|---|
| 820 | 1277 | | in this section shall apply to any vendor or downstream third party |
|---|
| 848 | 1278 | | that performs healthcare or administrative services on behalf of the |
|---|
| 849 | 1279 | | insurer that may receive or have access to rebate information. |
|---|
| 850 | 1280 | | SECTION 6. AMENDATORY 36 O.S. 2021, Section 6964, is |
|---|
| 851 | 1281 | | amended to read as follows: |
|---|
| 852 | 1282 | | Section 6964. A. A health insurer’s pharmacy and therapeutics |
|---|
| 853 | 1283 | | committee (P&T committee) of a health insurer or its agent, |
|---|
| 854 | 1284 | | including pharmacy benefits man agers (PBMs), shall establish a |
|---|
| 855 | 1285 | | formulary, which shall be a list of prescriptio n drugs, both generic |
|---|
| 856 | 1286 | | and brand name, used by practitioners to identify drugs that offer |
|---|
| 857 | 1338 | | the greatest overall value. The P&T committee shall review the |
|---|
| 858 | 1339 | | formulary annually. |
|---|
| 859 | 1340 | | B. A health insurer shall prohibit c onflicts of interest for |
|---|
| 860 | 1341 | | members of the P&T com mittee. The P&T committee shall meet the |
|---|
| 861 | 1342 | | following requirements: |
|---|
| 862 | 1343 | | 1. A person may not serve on a P&T committee if the person is |
|---|
| 863 | 1344 | | currently employed or was employe d within the preceding year by a |
|---|
| 864 | 1345 | | pharmaceutical manufacturer, developer, labeler, wholesaler or |
|---|
| 865 | 1346 | | distributor.; |
|---|
| 866 | 1347 | | 2. A majority of P&T committee members shall be practicing |
|---|
| 867 | 1348 | | physicians, practicing pharmacists, or both, and shall be licensed |
|---|
| 868 | 1349 | | in this state; |
|---|
| 869 | 1350 | | 3. A health insurer shall require any member of th e P&T |
|---|
| 870 | 1351 | | committee to disclose any compensation or funding from a |
|---|
| 871 | 1352 | | pharmaceutical manufacturer, developer, labeler, wholesaler or |
|---|
| 899 | 1353 | | distributor. Such P&T committee member shall be recuse d from voting |
|---|
| 900 | 1354 | | on any product manufactured or sold by such pharmaceutical |
|---|
| 901 | 1355 | | manufacturer, developer, labeler, wholesaler or di stributor.; |
|---|
| 902 | 1356 | | 4. P&T committee members shall practice in various clinical |
|---|
| 903 | 1357 | | specialties that adequately represent the needs of the health plan |
|---|
| 904 | 1358 | | enrollees and there shall be an adequate number, to be determined by |
|---|
| 905 | 1359 | | the Insurance Department, of high-volume specialists and specialists |
|---|
| 906 | 1360 | | treating rare or orphan diseases; |
|---|
| 907 | 1361 | | 5. The P&T committee shall meet at least on a quarterly basis; |
|---|
| 908 | 1413 | | 6. P&T committee formulary development shall be conducted |
|---|
| 909 | 1414 | | pursuant to a transparent process, and formulary decisions and |
|---|
| 910 | 1415 | | rationale shall be documented in writing. Upon request, the records |
|---|
| 911 | 1416 | | and documents shall be made available to the health plan, subject to |
|---|
| 912 | 1417 | | the conditions in subsection C of this section; |
|---|
| 913 | 1418 | | 7. If the P&T committee relies upon any third party to provide |
|---|
| 914 | 1419 | | cost-effectiveness analysis or research for a Medicaid managed care |
|---|
| 915 | 1420 | | organization’s prescription drug policy , the P&T committee shall: |
|---|
| 916 | 1421 | | a. disclose to the health benefit plan, the President Pro |
|---|
| 917 | 1422 | | Tempore of the Senate, the Speaker of the House of |
|---|
| 918 | 1423 | | Representatives, and the Governor, the name of a |
|---|
| 919 | 1424 | | relevant third party, and |
|---|
| 920 | 1425 | | b. provide a process through which patients and providers |
|---|
| 921 | 1426 | | potentially impacted by the third party’s analysis or |
|---|
| 922 | 1427 | | research may provide input to the P&T committee; |
|---|
| 950 | 1428 | | 8. P&T committee members who are s pecialists with current |
|---|
| 951 | 1429 | | clinical expertise and actively treat patients in a specific |
|---|
| 952 | 1430 | | therapeutic area, and the specific conditions within a therapeutic |
|---|
| 953 | 1431 | | area, shall participate in formulary decisions regarding each |
|---|
| 954 | 1432 | | therapeutic area and specific condit ion; |
|---|
| 955 | 1433 | | 9. The P&T committee shall base its clinical decisions on the |
|---|
| 956 | 1434 | | strength of scientific evidence, standards of practice, and |
|---|
| 957 | 1435 | | nationally accepted treatment guidelines; |
|---|
| 958 | 1487 | | 10. The P&T committee shall consider whether a particular drug |
|---|
| 959 | 1488 | | has a clinically meaningful therapeutic advantage over other drugs |
|---|
| 960 | 1489 | | in terms of safety, effectiveness, or clinical outcome for patient |
|---|
| 961 | 1490 | | populations who may be treated with the drug; |
|---|
| 962 | 1491 | | 11. The P&T committee shall evaluate and analyze treatment |
|---|
| 963 | 1492 | | protocols and procedures related to the health p lan’s formulary at |
|---|
| 964 | 1493 | | least annually; |
|---|
| 965 | 1494 | | 12. The P&T committee shall review formulary management |
|---|
| 966 | 1495 | | activities including exceptions and appeals processes, prior |
|---|
| 967 | 1496 | | authorization, step therapy, quantity limits, generic substitutions, |
|---|
| 968 | 1497 | | therapeutic interchange, and other drug utilization management |
|---|
| 969 | 1498 | | activities for clinical appropriateness and consistency with |
|---|
| 970 | 1499 | | industry standards and patient and provider organization guidelines; |
|---|
| 971 | 1500 | | 13. The P&T committee shall annually review and provide a |
|---|
| 972 | 1501 | | written report to the pharmacy benefits manager on: |
|---|
| 1008 | 1561 | | e. recommendations for improvement in formulary |
|---|
| 1009 | 1562 | | management practices consistent with patient and |
|---|
| 1010 | 1563 | | provider organization and other clinical g uidelines, |
|---|
| 1011 | 1564 | | provided that the report shall be subject to the |
|---|
| 1012 | 1565 | | conditions in subsection C of this section; and |
|---|
| 1013 | 1566 | | 14. The P&T committee shall review and make a formulary |
|---|
| 1014 | 1567 | | decision on a new United States Food and Drug Administration- |
|---|
| 1015 | 1568 | | approved drug within ninety (90) days of the drug’s approval, or |
|---|
| 1016 | 1569 | | shall provide a clinical justification if this timeframe is not met. |
|---|
| 1017 | 1570 | | C. The health insurer, its agents including pharmacy benefits |
|---|
| 1018 | 1571 | | managers, and the Department shall not publish or otherwise disclose |
|---|
| 1019 | 1572 | | any confidential, proprietary information including but not limited |
|---|
| 1020 | 1573 | | to any information that would disclose the identity of a specific |
|---|
| 1021 | 1574 | | health plan, the price or prices charged for a specific drug or |
|---|
| 1022 | 1575 | | class of drugs, the amount of any rebates provided for a specific |
|---|
| 1023 | 1576 | | drug or class of drugs, the manufacturer, or that would otherwise |
|---|
| 1058 | 1635 | | or administrative services on behalf of the pharmacy ben efits |
|---|
| 1059 | 1636 | | manager that may receive or have access to rebate information. |
|---|
| 1060 | 1637 | | SECTION 7. AMENDATORY 51 O.S. 2021, Section 24A. 3, as |
|---|
| 1061 | 1638 | | last amended by Section 1, Chapter 402, O.S.L. 2022 (51 O.S. Supp. |
|---|
| 1062 | 1639 | | 2022, Section 24A.3), is amended to r ead as follows: |
|---|
| 1063 | 1640 | | Section 24A.3. As used in the Oklahoma Open Records Act: |
|---|
| 1064 | 1641 | | 1. “Record” means all documents including, but not limited to, |
|---|
| 1065 | 1642 | | any book, paper, photograph, microfilm, data files cre ated by or |
|---|
| 1066 | 1643 | | used with computer softw are, computer tape, disk, record , sound |
|---|
| 1067 | 1644 | | recording, film recording, video record or other material regardless |
|---|
| 1068 | 1645 | | of physical form or characteristic, created by, received by, under |
|---|
| 1069 | 1646 | | the authority of, or coming into the custody, control or possession |
|---|
| 1070 | 1647 | | of public officials, public bodies or their representatives in |
|---|
| 1071 | 1648 | | connection with the transaction of public bus iness, the expenditure |
|---|
| 1072 | 1649 | | of public funds or the administering of public property. “Record” |
|---|
| 1073 | 1650 | | does not mean: |
|---|
| 1074 | 1651 | | a. computer software, |
|---|
| 1109 | 1710 | | public body for the purpose of evaluating credit |
|---|
| 1110 | 1711 | | worthiness, obtaining a license, permit or for the |
|---|
| 1111 | 1712 | | purpose of becoming qualified to contract with a |
|---|
| 1112 | 1713 | | public body, |
|---|
| 1113 | 1714 | | e. any digital audio/video re cordings of the toll |
|---|
| 1114 | 1715 | | collection and safeguarding activities of the Oklahoma |
|---|
| 1115 | 1716 | | Transportation Authority, |
|---|
| 1116 | 1717 | | f. any personal information provided by a guest at any |
|---|
| 1117 | 1718 | | facility owned or operated by the Oklahoma Tourism and |
|---|
| 1118 | 1719 | | Recreation Department to obtain any service at the |
|---|
| 1119 | 1720 | | facility or by a purchaser of a product sold by or |
|---|
| 1120 | 1721 | | through the Oklahoma Tourism and Recreation |
|---|
| 1121 | 1722 | | Department, |
|---|
| 1122 | 1723 | | g. a Department of Defense Form 214 (DD Form 214) filed |
|---|
| 1123 | 1724 | | with a county clerk including any DD Form 214 filed |
|---|
| 1124 | 1725 | | before July 1, 2002, |
|---|
| 1160 | 1785 | | 18 United States Code, Sections 2721 thro ugh |
|---|
| 1161 | 1786 | | 2725, which are stored and maintained by the |
|---|
| 1162 | 1787 | | Department of Public Safety, or |
|---|
| 1163 | 1788 | | i. any portion of any document or information provided to |
|---|
| 1164 | 1789 | | an agency or entity of th e state or a political |
|---|
| 1165 | 1790 | | subdivision to obtain licensure under the laws of this |
|---|
| 1166 | 1791 | | state or a political subdivision that contain s an |
|---|
| 1167 | 1792 | | applicant’s personal address, personal phone number, |
|---|
| 1168 | 1793 | | personal electronic mail address or other c ontact |
|---|
| 1169 | 1794 | | information. Provided, h owever, lists of persons |
|---|
| 1170 | 1795 | | licensed, the existence of a license of a person, or a |
|---|
| 1171 | 1796 | | business or commercial address, or other bu siness or |
|---|
| 1172 | 1797 | | commercial information disclosable under state law |
|---|
| 1173 | 1798 | | submitted with an application for licens ure shall be |
|---|
| 1174 | 1799 | | public record, or |
|---|
| 1202 | 1800 | | j. for the purposes of the Patient’s Right to Pharmacy |
|---|
| 1203 | 1801 | | Choice Act, any information or record that would have |
|---|
| 1204 | 1802 | | the potential to compr omise the financial, |
|---|
| 1205 | 1803 | | competitive, or proprietary nature of information |
|---|
| 1206 | 1804 | | about a specific drug or class of drugs, or a specific |
|---|
| 1207 | 1805 | | product or therapeutic class of products. Additional |
|---|
| 1208 | 1806 | | information that shall not be disclosed includes but |
|---|
| 1209 | 1807 | | is not limited to: |
|---|
| 1210 | 1859 | | (1) any information relating to specific drugs or |
|---|
| 1211 | 1860 | | classes of drugs that would disclose the identity |
|---|
| 1212 | 1861 | | of a specific health plan, dru g prices, the |
|---|
| 1213 | 1862 | | rebate amount received by a pharmacy benefits |
|---|
| 1214 | 1863 | | manager, the rebate amount received by the |
|---|
| 1215 | 1864 | | insurer, or the identity of the manufacturer, and |
|---|
| 1216 | 1865 | | (2) any information relating to a p roduct or |
|---|
| 1217 | 1866 | | therapeutic class of products that would disclose |
|---|
| 1218 | 1867 | | the rebate received by a pharmacy benefits |
|---|
| 1219 | 1868 | | manager, the rebate amount received by an |
|---|
| 1220 | 1869 | | insurer, or the identity of the manufacturer; |
|---|
| 1221 | 1870 | | 2. “Public body” shall include, but not be limited to, any |
|---|
| 1222 | 1871 | | office, department, board, bureau, commissio n, agency, trusteesh ip, |
|---|
| 1223 | 1872 | | authority, council, committee, trust or any entity cr eated by a |
|---|
| 1224 | 1873 | | trust, county, city, village, town, township, district, school |
|---|
| 1225 | 1874 | | district, fair board, court, executive office, advisory group, tas k |
|---|
| 1253 | 1875 | | force, study group or any subdivision thereof, supported in whole or |
|---|
| 1254 | 1876 | | in part by public funds or entrusted with th e expenditure of public |
|---|
| 1255 | 1877 | | funds or administering or operating public property, and all |
|---|
| 1256 | 1878 | | committees, or subcommittees thereof. Except for the re cords |
|---|
| 1257 | 1879 | | required by Section 24A.4 of this title, “public body” does not mean |
|---|
| 1258 | 1880 | | judges, justices, the Council on Judicia l Complaints, the |
|---|
| 1259 | 1881 | | Legislature or legislators. “Public body” shall not include an |
|---|
| 1260 | 1882 | | organization that is exempt from federal income tax under S ection |
|---|
| 1261 | 1934 | | 501(c)(3) of the Internal Revenu e Code of 1986, as amended, and |
|---|
| 1262 | 1935 | | whose sole beneficiary is a college or university, or an affiliated |
|---|
| 1263 | 1936 | | entity of the college or university, that is a member of The |
|---|
| 1264 | 1937 | | Oklahoma State System of Higher Education. Such organization shall |
|---|
| 1265 | 1938 | | not receive direct appropri ations from the Oklahoma Legislature. |
|---|
| 1266 | 1939 | | The following persons shall not b e eligible to serve as a voting |
|---|
| 1267 | 1940 | | member of the governing board of the organization: |
|---|
| 1268 | 1941 | | a. a member, officer, or employee of the Oklahoma State |
|---|
| 1269 | 1942 | | Regents for Higher Education , |
|---|
| 1270 | 1943 | | b. a member of the board of regents or other governing |
|---|
| 1271 | 1944 | | board of the college or university th at is the sole |
|---|
| 1272 | 1945 | | beneficiary of the organization, or |
|---|
| 1273 | 1946 | | c. an officer or employee of the college or university |
|---|
| 1274 | 1947 | | that is the sole beneficiary of th e organization; |
|---|
| 1275 | 1948 | | 3. “Public office” means the physical location where public |
|---|
| 1276 | 1949 | | bodies conduct business or keep record s; |
|---|
| 1304 | 1950 | | 4. “Public official” means any official or employee of any |
|---|
| 1305 | 1951 | | public body as defined herein; and |
|---|
| 1306 | 1952 | | 5. “Law enforcement agency” means any public body charged with |
|---|
| 1307 | 1953 | | enforcing state or local criminal laws and initiating criminal |
|---|
| 1308 | 1954 | | prosecutions including, but not limited to, police departments, |
|---|
| 1309 | 1955 | | county sheriffs, the Department of Public Safety, the Oklahoma State |
|---|
| 1310 | 1956 | | Bureau of Narcotics and Dangerous Drugs Control, the Alcoholic |
|---|
| 1311 | 2008 | | Beverage Laws Enforcement Commission, and the Oklahoma State Bureau |
|---|
| 1312 | 2009 | | of Investigation. |
|---|
| 1313 | 2010 | | SECTION 8. AMENDATORY 5 9 O.S. 2021, Section 357, is |
|---|
| 1314 | 2011 | | amended to read as foll ows: |
|---|
| 1315 | 2012 | | Section 357. As used in this act the Oklahoma Pharmacy Act : |
|---|
| 1316 | 2013 | | 1. “Covered entity” means a nonprofit hospi tal or medical |
|---|
| 1317 | 2014 | | service organization, insurer, health coverage plan or health |
|---|
| 1318 | 2015 | | maintenance organization; a health program administered by the state |
|---|
| 1319 | 2016 | | in the capacity of pro vider of health coverage; or an employer, |
|---|
| 1320 | 2017 | | labor union, or other entity organized in the state that provides |
|---|
| 1321 | 2018 | | health coverage to covered individuals who are employed or reside in |
|---|
| 1322 | 2019 | | the state. This term does not include a health plan that provides |
|---|
| 1323 | 2020 | | coverage only for accidental injury, specified disease, hospi tal |
|---|
| 1324 | 2021 | | indemnity, disability income, or ot her limited benefit health |
|---|
| 1325 | 2022 | | insurance policies and contracts that do not include prescription |
|---|
| 1326 | 2023 | | drug coverage; |
|---|
| 1361 | 2082 | | 4. “Maximum allowable cost” or “MAC” means the list of drug |
|---|
| 1362 | 2083 | | products delineating the maximum per -unit reimbursement for |
|---|
| 1363 | 2084 | | multiple-source prescription drugs, m edical product or devi ce; |
|---|
| 1364 | 2085 | | 5. “Multisource drug product reimbursement ” (reimbursement) |
|---|
| 1365 | 2086 | | means the total amount paid to a pharmacy inclusive of any reduction |
|---|
| 1366 | 2087 | | in payment to the pharmacy, excluding prescripti on dispense fees; |
|---|
| 1367 | 2088 | | 6. “Pharmacy benefits management ” means a service provi ded to |
|---|
| 1368 | 2089 | | covered entities to facilitate the provisi on of prescription drug |
|---|
| 1369 | 2090 | | benefits to covered individuals within the s tate, including |
|---|
| 1370 | 2091 | | negotiating pricing and other terms with drug man ufacturers and |
|---|
| 1371 | 2092 | | providers. Pharmacy benefits managem ent may include any or all of |
|---|
| 1372 | 2093 | | the following services: |
|---|
| 1373 | 2094 | | a. claims processing, performance of drug utilization |
|---|
| 1374 | 2095 | | review, processing of prior authorization requests, |
|---|
| 1375 | 2096 | | retail network management and payment of cla ims to |
|---|
| 1376 | 2097 | | pharmacies for prescription drugs dispensed t o covered |
|---|
| 1377 | 2098 | | individuals, |
|---|
| 1411 | 2156 | | f. adjudication of appeals or grievances rela ted to the |
|---|
| 1412 | 2157 | | prescription drug ben efit, and |
|---|
| 1413 | 2158 | | g. oversight of prescriptio n drug costs; |
|---|
| 1414 | 2159 | | 7. “Pharmacy benefits manager” or “PBM” means a person, |
|---|
| 1415 | 2160 | | business or other entity that, either directly or through an |
|---|
| 1416 | 2161 | | intermediary, performs pharmacy benefit s management. The term |
|---|
| 1417 | 2162 | | includes a person or ent ity acting for a PBM in a contractual or |
|---|
| 1418 | 2163 | | employment relationship in the performance of pharmacy benefits |
|---|
| 1419 | 2164 | | management for a managed car e company, nonprofit hospital, medical |
|---|
| 1420 | 2165 | | service organization, insurance comp any, third-party payor, or a |
|---|
| 1421 | 2166 | | health program administered by an agency of this state; |
|---|
| 1422 | 2167 | | 8. “Plan sponsor” means the employers, insurance companies, |
|---|
| 1423 | 2168 | | unions and health maintenance organ izations or any other entity |
|---|
| 1424 | 2169 | | responsible for establi shing, maintaining, or administering a health |
|---|
| 1425 | 2170 | | benefit plan on behalf of covered individuals; and |
|---|
| 1426 | 2171 | | 9. “Provider” means a pharmacy licensed b y the State Board of |
|---|
| 1427 | 2172 | | Pharmacy, or an agent or representative of a pharmacy, including, |
|---|
| 1455 | 2173 | | but not limited to, the pharmacy’s contracting agent, which |
|---|
| 1456 | 2174 | | dispenses prescription drugs or devices t o covered individuals. |
|---|
| 1457 | 2175 | | SECTION 9. AMENDATORY 59 O.S. 2021, Section 358, is |
|---|
| 1458 | 2176 | | amended to read as follows: |
|---|
| 1459 | 2177 | | Section 358. A. In order to provide pharmacy benefits |
|---|
| 1460 | 2178 | | management or any of the services inclu ded under the definit ion of |
|---|
| 1461 | 2179 | | pharmacy benefits management in this stat e, a pharmacy benefits |
|---|
| 1462 | 2231 | | manager or any entity acting as one in a contractual or employment |
|---|
| 1463 | 2232 | | relationship for a covered entity shall first obtain a lic ense from |
|---|
| 1464 | 2233 | | the Oklahoma Insurance Department, and the Departm ent may charge a |
|---|
| 1465 | 2234 | | fee for such licensure. |
|---|
| 1466 | 2235 | | B. The Department shall establish, by regulation, licensure |
|---|
| 1467 | 2236 | | procedures, required disclosures for pharm acy benefits managers |
|---|
| 1468 | 2237 | | (PBMs) and other rules as may be necessary for carrying out and |
|---|
| 1469 | 2238 | | enforcing the provisions of this act the Oklahoma Pharmacy Act. The |
|---|
| 1470 | 2239 | | licensure procedures shall, at a minimum, include the completion of |
|---|
| 1471 | 2240 | | an application form that shall in clude the name and address of an |
|---|
| 1472 | 2241 | | agent for service of process, the payment of a requisite fee, and |
|---|
| 1473 | 2242 | | evidence of the procurement of a suret y bond: |
|---|
| 1474 | 2243 | | 1. The name, address, and telephone contact number of the PBM ; |
|---|
| 1475 | 2244 | | 2. The name and address of the PBM’s agent for service of |
|---|
| 1476 | 2245 | | process in the state; |
|---|
| 1477 | 2246 | | 3. The name and address of each person with management or |
|---|
| 1478 | 2247 | | control over the PBM; |
|---|
| 1506 | 2248 | | 4. Evidence of the procurement of a surety bond; |
|---|
| 1507 | 2249 | | 5. The name and address of each person with a ben eficial |
|---|
| 1508 | 2250 | | ownership interest in the PBM; |
|---|
| 1509 | 2251 | | 6. In the case of a PBM applicant that is a partnership or |
|---|
| 1510 | 2252 | | other unincorporated association, limited liability company , or |
|---|
| 1511 | 2253 | | corporation, and has five or more partners, members, or |
|---|
| 1512 | 2254 | | stockholders, the applicant shall: |
|---|
| 1513 | 2306 | | a. specify its legal structure and the total number of |
|---|
| 1514 | 2307 | | its partners, members, or stockholders, |
|---|
| 1515 | 2308 | | b. specify the name, address, usual occupation, and |
|---|
| 1516 | 2309 | | professional qualifications of the five partners, |
|---|
| 1517 | 2310 | | members, or stockholders with the five largest |
|---|
| 1518 | 2311 | | ownership interests in the PBM, and |
|---|
| 1519 | 2312 | | c. upon request by the Department, furnish the Department |
|---|
| 1520 | 2313 | | with information regarding the name, address, usual |
|---|
| 1521 | 2314 | | occupation, and professional qualifications of any |
|---|
| 1522 | 2315 | | other partners, members, or stockholders; and |
|---|
| 1523 | 2316 | | 7. A signed statement in dicating that the PBM has not been |
|---|
| 1524 | 2317 | | convicted of a felony and has not violated any of the requirements |
|---|
| 1525 | 2318 | | of the Oklahoma Pharmacy Act and the Patient ’s Right to Pharmacy |
|---|
| 1526 | 2319 | | Choice Act, or, if the applicant cannot provide such a statement, a |
|---|
| 1527 | 2320 | | signed statement descr ibing any relevant conviction or violation. |
|---|
| 1528 | 2321 | | C. The Department may subpoena witnesses and info rmation. Its |
|---|
| 1529 | 2322 | | compliance officers may take and copy records for i nvestigative use |
|---|