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2015 SESSION

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HB 2031 Health insurance; updating maximum allowable cost pricing lists.

Introduced by: Joseph R. Yost | all patrons    ...    notes | add to my profiles | history

SUMMARY AS PASSED:

Health insurance; updating maximum allowable cost pricing lists. Requires any contract between a health insurance carrier and its intermediary, pursuant to which the intermediary has the right or obligation to establish a maximum allowable cost, and any provider contract between a carrier and a participating pharmacy provider or its contracting agent, pursuant to which the carrier has the right or obligation to establish a maximum allowable cost, to contain specific provisions that require the intermediary or carrier to update, not less frequently than once every seven days, the maximum allowable cost list, unless there has been no change to the maximum allowable cost of any drug on the list since the last update. Such contracts are also required to contain specific provisions that require the intermediary or carrier to (i) verify, not less frequently than once every seven days, that the drugs on the maximum allowable cost list are available to participating pharmacy providers from at least one regional or national pharmacy wholesaler and that the amount for each drug is not obsolete and promptly revise the maximum allowable cost if necessary to comply with these required contractual provisions; (ii) provide a process for each participating pharmacy provider to readily access the maximum allowable cost list specific to that provider; and (iii) prohibit the intermediary or carrier from terminating or failing to renew its contractual relationship with a participating pharmacy provider for invoking its rights under any of these required contractual provisions. Such contracts are also required to contain provisions that require the intermediary or carrier to provide a process for an appeal, investigation, and resolution of disputes regarding maximum allowable cost drug pricing. The State Corporation Commission shall not have jurisdiction to adjudicate individual controversies arising out of this measure.

SUMMARY AS PASSED HOUSE:

Health insurance; updating maximum allowable cost pricing lists. Requires any contract between a health insurance carrier and its intermediary, pursuant to which the intermediary has the right or obligation to establish a maximum allowable cost, and any provider contract between a carrier and a participating pharmacy provider or its contracting agent, pursuant to which the carrier has the right or obligation to establish a maximum allowable cost, to contain specific provisions that require the intermediary or carrier to update, not less frequently than once every seven days, the maximum allowable cost list, unless there has been no change to the maximum allowable cost of any drug on the list since the last update. Such contracts are also required to contain specific provisions that require the intermediary or carrier to (i) verify, not less frequently than once every seven days, that the drugs on the maximum allowable cost list are available to participating pharmacy providers from at least one regional or national pharmacy wholesaler and that the amount for each drug is not obsolete and promptly revise the maximum allowable cost if necessary to comply with these required contractual provisions; (ii) provide a process for each participating pharmacy provider to readily access the maximum allowable cost list specific to that provider; and (iii) prohibit the intermediary or carrier from terminating or failing to renew its contractual relationship with a participating pharmacy provider for invoking its rights under any of these required contractual provisions. Such contracts are also required to contain provisions that require the intermediary or carrier to provide a process for an appeal, investigation, and resolution of disputes regarding maximum allowable cost drug pricing. The State Corporation Commission shall not have jurisdiction to adjudicate individual controversies arising out of this measure.

SUMMARY AS INTRODUCED:

Health insurance; updating maximum allowable cost pricing lists. Requires any pharmacy benefits contract or provider contract entered into, amended, extended, or renewed on or after January 1, 2016, that provides for the use of maximum allowable cost as the basis for the amount of any reimbursement or payment of claims to a pharmacist or other person, to contain specific provisions that require the health carrier and pharmacy benefits administrator to update, not less frequently than once every seven days, any maximum allowable cost pricing list that is required or permitted to be used in connection with the pharmacy benefits contract or provider contract. A copy of each updated maximum allowable cost pricing list shall be provided to applicable pharmacists in advance of its use in connection with any reimbursement or payment of claims. The legislation establishes private rights of action for providers who suffer actual damages resulting from carrier violations of the bill's provisions. Providers are entitled to recover treble damages for any willful violations. The State Corporation Commission is given oversight concerning the bill's provisions.