HB 458 -- Pharmacy Benefit Managers

Sponsor:  Stevenson

This bill establishes regulations regarding pharmacy benefit
managers.  In its main provisions, the bill:

(1)  Requires pharmacy benefit managers to disclose to the
covered person or entity all information pertaining to individual
claims, along with an itemized invoice of the actual amounts paid
to each pharmacist and pharmacy;

(2)  Prohibits pharmacy benefit managers from enrolling
pharmacies in contracts or modifying an existing contract without
a signed affirmation from the pharmacy or pharmacist, from
requiring pharmacies or pharmacists from participating in a
contract in order to participate in another, and from
discriminating between pharmacies or pharmacists on the basis of
co-payments or days of supply;

(3)  Requires pharmacy benefit managers to use the same National
Drug Code price when calculating the reimbursement to the
dispensing pharmacy;

(4)  Requires prescriptions or modifications to a prescription to
remain with the original pharmacy within the pharmacy benefit
manager's network and not be reassigned to a different pharmacy;

(5)  Prohibits health benefit plans which provide prescription
coverage from reducing, limiting, or denying coverage for any
drugs in certain situations;

(6)  Specifies that an insurer is allowed to make uniform changes
in its benefit design that apply to all covered drugs, uniformly
remove a drug from the formulary list for all insureds, or
increase cost-sharing obligations only due to a percentage
co-insurance payment that necessarily increases with an increase
in the underlying drug prices;

(7)  Requires all switch communications to clearly identify the
originally prescribed medication and disclose any financial
interest that the health care insurer, pharmacy benefit manager,
or prescribing physician has in the patient's decision to switch
medications.  The patient must also be advised of his or her
rights regarding the proposed change and any cost-sharing changes
for which he or she is responsible.  A copy of any switch
communication must also be sent to the prescribing practitioner.
Any person who issues or delivers or causes to be issued or
delivered a switch communication that has not been approved,
provides a misrepresentation or false statement in a switch
communication, or commits any other material violation of these
provisions will be subject to a fine of up to $25,000; and

(8)  Allows the prescribing physician to override any step
therapy or fail first protocol when the treatment has been
ineffective in treating the patient's disease or medical
condition or based on sound clinical evidence and medical and
scientific evidence is expected to be ineffective or is likely to
cause an adverse reaction or other harm.  The duration of any
step therapy or fail first protocol cannot last longer than 14
days.  For medications with no generic equivalent and for which
the prescribing physician feels there is no appropriate
therapeutic alternative, the health carrier or pharmacy benefit
manager is required to provide access to medications labeled by
the United States Food and Drug Administration without
restriction.

Missouri House of Representatives
95th General Assembly, 1st Regular Session
Last Updated November 17, 2009 at 9:24 am