Relating to pharmacy benefit managers and health carriers and management of prescription drug benefits, and including applicability provisions

“Pharmacy benefits manager” is defined in the bill as a person who, pursuant to a contract or an employment relationship with a health carrier, either directly or through an affiliate or intermediary, manages a prescription drug benefit provided by the health carrier. The bill defines a “health carrier” as an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, including an insurance company offering sickness and accident plans, a health maintenance organization, a nonprofit health service corporation, a plan established pursuant to Code chapter 509A for public employees, or any other entity providing a plan of health insurance, health care benefits, or health care services. The commissioner is required to make the information provided by the pharmacy benefit managers available on a publicly accessible internet site. The bill prohibits the pharmacy benefits manager or the commissioner from providing the information in a manner that identifies a specific health carrier, a specific price charged by a pharmaceutical manufacturer, or the amount of rebates received by a pharmacy benefit manager for a specific drug or class of drug. If information submitted to the commissioner by the pharmacy benefits manager does contain any of these details, the information is deemed confidential and proprietary and is a confidential record pursuant to Code chapter 22. For each health carrier’s health benefit plan for which a pharmacy benefit manager is contracted to manage the prescription drug benefit, the bill requires the pharmacy benefit manager to publish the formulary on an internet site that is easily accessible to the public. The pharmacy benefit manager is also required to post any formulary changes, and a notification of any prescription drug that the health carrier, the health benefit plan, or the pharmacy benefit manager excludes from coverage, a minimum of calendar days prior to implementation of the formulary changes or prescription drug exclusions. The bill requires a pharmacy benefit manager that manages a health carrier’s prescription drug benefit to review the health carrier’s formulary at least annually, utilizing an independent pharmacy and therapeutics committee. The requirements for the membership of the committee and the duties of the committee are detailed in the bill.7, subsection 3. The bill prohibits a health carrier from imposing a cost sharing requirement on a covered person for a prescription drug that exceeds an amount equal to the greater of either the dollar amount of percent or more of the aggregate rebates received by the health carrier, or an amount that ensures that the covered person’s cost sharing for the prescription drug shall not exceed percent of the health carrier’s cost for the prescription drug. “Covered person” is defined in the bill as a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan. A health carrier is prohibited from disclosing any information regarding the actual amount of rebates the health carrier received for a specific drug, or from a specific pharmaceutical manufacturer, or from a specific pharmacy in order to comply with the cost sharing requirement. Rebate information is protected as a trade secret and is a confidential record. A health carrier is also required to have an agreement with the health carrier’s third-party vendors and downstream entities as necessary to ensure the information is protected as a trade secret. The bill requires the commissioner of insurance to adopt rules as necessary to administer the provisions of the bill. The bill also allows the commissioner to take any action within the commissioner’s authority to enforce compliance with the provisions of the bill. The bill is applicable to health benefit plans that are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2020.