What changed in SF 563
The bill as introduced, compared with the version both chambers passed (88th General Assembly). 2 adopted amendments account for the changes.
1 passage reworded, 0 added and 36 removed; 43 of 80 unchanged.
Removed AddedIntroduced textText as passedAmendments
Section 1.
41 unchanged passages
NEW SECTION. 510C.1 Definitions. As used in this chapter unless the context otherwise requires:
1. “Administrative fees” means a fee or payment, other than a rebate, under a contract between a pharmacy benefit manager and a pharmaceutical drug manufacturer in connection with the pharmacy benefit manager’s management of a health carrier’s prescription drug benefit, that is paid by a pharmaceutical drug manufacturer to a pharmacy benefit manager or is retained by the pharmacy benefit manager.
2. “Aggregate retained rebate percentage” means the percentage of all rebates received by a pharmacy benefit manager that is not passed on to the pharmacy benefit manager’s health carrier clients.
3. “Commissioner” means the commissioner of insurance.
4. “Covered person” means the same as defined in section 514J.102.
5. “Formulary” means a complete list of prescription drugs eligible for coverage under a health benefit plan.
6. “Health benefit plan” means the same as defined in section 514J.102.
7. “Health carrier” means the same as defined in section 514J.102.
8. “Health carrier administrative service fee” means a fee or payment under a contract between a pharmacy benefit manager and a health carrier in connection with the pharmacy benefit manager’s administration of the health carrier’s prescription drug benefit that is paid by a health carrier to a pharmacy benefit manager or is otherwise retained by a pharmacy benefit manager.
9. “Pharmacy benefit manager” means 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.
10. “Prescription drug benefit” means a health benefit plan providing for third-party payment or prepayment for prescription drugs.
11. “Rebate” means all discounts and other negotiated price concessions paid directly or indirectly by a pharmaceutical manufacturer or other entity, other than a covered person, in the prescription drug supply chain to a pharmacy benefit manager, and which may be based on any of the following:
a. A pharmaceutical manufacturer’s list price for a prescription drug.
b. Utilization.
c. To maintain a net price for a prescription drug for a specified period of time for the pharmacy benefit manager in the event the pharmaceutical manufacturer’s list price increases.
d. Reasonable estimates of the volume of a prescribed drug that will be dispensed by a pharmacy to covered persons.
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NEW SECTION. 510C.2 Annual report to the commissioner.
1. Each pharmacy benefit manager shall provide a report annually by February 15 to the commissioner that contains all of the following information regarding prescription drug benefits provided to covered persons of each health carrier with whom the pharmacy manager has contracted during the prior calendar year:
a. The aggregate dollar amount of all rebates received by the pharmacy benefit manager.
b. The aggregate dollar amount of all administrative fees received by the pharmacy benefit manager.
c. The aggregate dollar amount of all health carrier administrative service fees received by the pharmacy benefit manager.
d. The aggregate dollar amount of all rebates received by the pharmacy benefit manager that the pharmacy benefit manager did not pass through to the health carrier.
e. The aggregate amount of all administrative fees received by the pharmacy benefit manager that the pharmacy benefit manager did not pass through to the health carrier.
f. The aggregate retained rebate percentage as calculated by dividing the dollar amount in paragraph “d” by the dollar amount in paragraph “a”.
g. Across all health carrier clients with whom the pharmacy manager was contracted, the highest and the lowest aggregate retained rebate percentages.
2.
a. A pharmacy benefit manager shall provide the information pursuant to subsection 1 to the commissioner in a format approved by the commissioner that does not directly or indirectly disclose any of the following:
(1) The identity of a specific health carrier.
(2) The price charged by a specific pharmaceutical manufacturer for a specific prescription drug or for a class of prescription drugs.
(3) The amount of rebates provided for a specific prescription drug or class of prescription drugs.
b. Information provided under this section by a pharmacy benefit manager to the commissioner that may reveal the identity of a specific health carrier, the price charged by a specific pharmaceutical manufacturer for a specific prescription drug or class of prescription drugs, or the amount of rebates provided for a specific prescription drug or class of prescription drugs shall be considered a confidential record and be recognized and protected as a trade secret pursuant to section 22.7, subsection 3.
3. The commissioner shall publish, within sixty calendar days of receipt, the nonconfidential information received by the commissioner on a publicly accessible internet site. The information shall be made available to the public in a format that complies with subsection 2, paragraph “a”.
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NEW SECTION. 510C.3 Rules. The commissioner of insurance shall adopt rules pursuant to chapter 17A as necessary to administer this chapter.
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NEW SECTION. 510C.4 Enforcement. The commissioner may take any action within the commissioner’s authority to enforce compliance with this chapter.
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NEW SECTION. 510C.5 Applicability. This chapter is applicable to a health benefit plan that is delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2020. 2019.
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NEW SECTION. 514M.1 Definitions. As used in this chapter, unless the context otherwise requires:
1. “Commissioner” means the commissioner of insurance.
2. “Cost sharing” means any copayment, coinsurance, deductible, or other out-of-pocket expense requirement.
3. “Covered person” means the same as defined in section 514J.102.
4. “Health benefit plan” means the same as defined in section 514J.102.
5. “Health carrier” means the same as defined in section 514J.102.
6. “Health carrier cost” means the amount that a health carrier has contracted with a dispensing pharmacy to pay the dispensing pharmacy for a covered prescription drug, after accounting for rebates, and excluding a covered person’s cost sharing.
7. “Pharmacy benefits manager” means the same as defined in 510C.1.
8. “Prescription drug benefit” means the same as defined in section 510C.1.
9. “Rebate” means any of the following:
a. A negotiated price concession for a prescription drug that may accrue directly or indirectly to a health carrier during a health benefit plan coverage year from a pharmaceutical manufacturer, a dispensing pharmacy, or from another entity in the prescription drug supply chain taking part in a transaction involving a pharmaceutical manufacturer’s prescription drug and which may be based on any of the following:
(1) A pharmaceutical manufacturer’s list price for a prescription drug.
(2) Patient outcomes.
(3) A reasonable estimate of price concessions necessary to maintain the net price of a prescription drug for the health carrier for a specified period of time in the event the pharmaceutical manufacturer’s list price increases.
b. A reasonable estimate of fees and other administrative costs that are passed through to the health carrier by the pharmaceutical manufacturer.
10. “Trade secret” means the same as defined in section 550.2.
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NEW SECTION. 514M.2 Cost sharing —— prescription drug benefit.
1. If a health carrier provides prescription drug benefits to a covered person under a health benefit plan, the health carrier shall reduce any cost sharing requirement for a prescription drug for the covered person by an amount equal to the greater of the following:
a. A dollar amount that equals not less than fifty-one percent of the aggregate rebates received by the health carrier.
b. An amount that ensures that the covered person’s cost sharing for the prescription drug does not exceed fifty-one percent of the health carrier’s cost for the prescription drug.
2. A health carrier or health benefit plan may reduce a covered person’s cost sharing by an amount greater than the amount required pursuant to subsection 1.
3. In complying with this section, a health carrier and the health carrier’s agents shall not publish or otherwise disclose, directly or indirectly, any information regarding the actual amount of rebates the health carrier receives for a specific prescription drug, from a specific pharmaceutical manufacturer, or from a specific pharmacy. Rebate information is a trade secret under chapter 550 and is a confidential record under section 22.7, subsection 3.
4. A health carrier shall have a written agreement with any third-party vendor or downstream entity requiring the third-party vendor or downstream entity to comply with subsection 3 if the third-party vendor or downstream entity receives or has access to the health carrier’s rebate information in the course of performing any health care or administrative services on behalf of the health carrier.
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NEW SECTION. 514M.3 Rules. The commissioner of insurance shall adopt rules pursuant to chapter 17A as necessary to administer this chapter.
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NEW SECTION. 514M.4 Enforcement. The commissioner may take any action within the commissioner’s authority to enforce compliance with this chapter.
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NEW SECTION. 514M.5 Applicability. This chapter is applicable to a health benefit plan that is delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2020.