Relating to prescription drug benefits, pharmacies, pharmacy benefit managers, making penalties applicable, and including applicability provisions

The bill prohibits a pharmacy benefit manager or a health carrier from refusing to accept an otherwise qualified retail pharmacy as part of a pharmacy benefit manager’s retail pharmacy network. The bill defines a “pharmacy benefit manager” as a person who, pursuant to a contract or other relationship with a health carrier, either directly or through an intermediary, manages a prescription drug benefit provided by the health carrier. “Pharmacy” is defined in the bill as a location where prescription drugs are compounded, dispensed, or sold by a pharmacist and where prescription drug orders are received or processed in accordance with the pharmacy laws of this state. “Pharmacy benefit manager’s retail pharmacy network” is defined as retail pharmacies who have contracted with a pharmacy benefit manager to dispense or sell prescription drugs to covered persons of a health carrier. “Retail pharmacy” is defined as a pharmacy that is open to the general public, dispenses prescription drugs to the general public, and makes face-to-face consultations available between licensed pharmacists and the general public. A contractual relationship entered into by an otherwise qualified retail pharmacy and a pharmacy benefit manager establishing the otherwise qualified retail pharmacy as part of the pharmacy benefit manager’s retail pharmacy network must be renewed annually unless otherwise agreed by the retail pharmacy, the pharmacy benefit manager, and the health carrier. If a pharmacy benefit manager or a health carrier considers a retail pharmacy not otherwise qualified, the pharmacy benefit manager or the health carrier may file an appeal relating to the retail pharmacy’s qualifications with the insurance commissioner. The commissioner shall establish by rule the standards and requirements necessary for a retail pharmacy to be deemed “otherwise qualified”. If an otherwise qualified retail pharmacy is a part of a pharmacy benefit manager’s retail pharmacy network, the bill prohibits a pharmacy benefit manager or a health carrier from imposing certain specific restrictions and conditions on a covered person who obtains prescriptions from the retail pharmacy. The commissioner of insurance may assess a pharmacy benefit manager or a health carrier a fine of up to $10,000 for each violation. Each pharmacy benefit manager and health carrier must file an annual attestation with the commissioner confirming compliance with all requirements related to retail pharmacies and the pharmacy benefit manager’s retail pharmacy network for the preceding calendar year, which shall include a report disclosing certain information as described in the bill. The commissioner is required to examine the pharmacy benefit manager’s and the health carrier’s records supporting the accuracy and completeness of each report. The pharmacy benefit manager and health carrier are required to provide any additional records requested by the commissioner within ten business days of the commissioner’s request.3(3). The commissioner is authorized to take any action within the commissioner’s authority to enforce compliance with this section of the bill and must adopt rules to administer this section of the bill. A pharmacy benefit manager or a health carrier may appeal any decision, in accordance with chapter 17A, of the commissioner under this section. This section of the bill applies to a health benefit plan that is delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2020. The bill also prohibits a policy, contract, or plan providing for third-party payment or prepayment of prescription drug benefits from imposing any terms, conditions, or requirements upon a person covered under the policy, contract, or plan for prescription drugs dispensed by a retail pharmacy which are different from the terms, conditions, or requirements imposed for prescription drugs dispensed by a mail order pharmacy. This prohibition applies to the following classes of third-party payment provider policies, contracts, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2020, including individual or group accident and sickness insurance providing coverage on an expense-incurred basis; an individual or group hospital or medical service contract issued pursuant to Code chapter 509, 514, or 514A; an individual or group health maintenance organization contract regulated under Code chapter 514B; and a plan established pursuant to Code chapter 509A for public employees. The prohibition does not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance. The commissioner of insurance must adopt rules under Code chapter 17A to administer the requirements established in the bill.