HCS HB 95 -- PRESCRIPTION DRUGS AND PHARMACY BENEFIT MANAGERS
(Schaaf)

COMMITTEE OF ORIGIN:  Committee on Healthcare Transformation

This substitute changes the laws regarding co-payments for
prescription drugs and establishes regulations regarding pharmacy
benefit managers.

CO-PAYMENTS FOR PRESCRIPTION DRUGS

When the usual and customary retail price of a prescription drug
is less than the co-payment applied by a health maintenance
organization or health insurer, the enrollee will only be
required to pay the usual and customary retail price of the
prescription drug and there will be no further charge to the
enrollee or plan sponsor for the prescription.

PHARMACY BENEFIT MANAGERS

The substitute establishes regulations regarding pharmacy benefit
managers.  The substitute:

(1)  Requires pharmacy benefit managers to disclose on a monthly
basis to the plan sponsor a summary of all information pertaining
to each claim submitted to the pharmacy benefit manager;

(2)  Prohibits pharmacy benefit managers from enrolling
pharmacies in contracts or modifying an existing contract without
a written 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 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;

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

(5)  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;

(6)  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.  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

(7)  Allows the prescribing physician to override any step
therapy or fail first protocol when, based on sound clinical
evidence, 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.  However, if the health carrier
or pharmacy benefit manager can show the originally prescribed
medication is likely to require more than two weeks to provide
relief, the step therapy or fail first protocol can be extended
up to seven additional days.

FISCAL NOTE:  No impact on General Revenue Fund in FY 2010,
FY 2011, and FY 2012.  Estimated Cost on Other State Funds of
Unknown, could exceed $240,719 in FY 2010; Unknown, could exceed
$437,029 in FY 2011; and Unknown, could exceed $438,619 in
FY 2012.

Missouri House of Representatives
95th General Assembly, 1st Regular Session
Last Updated November 17, 2009 at 9:23 am