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ARIZONA STATE SENATE
Fifty-Fourth Legislature, First Regular Session
AMENDED
unfair claims practices; cost sharing
(NOW: insurance; cost-sharing; calculation)
Purpose
Requires a health care insurer, when calculating an enrollee's contribution, to include certain cost-sharing amounts paid by an enrollee.
Background
Current statute defines a pharmacy benefits manager as a person, business or other entity that, pursuant to a contract or under an employment relationship with a carrier or other third-party payer, either directly or through an intermediary manages the prescription drug coverage provided by the carrier or other third-party payer, including the processing and payment of claims for prescription drugs, the performance of drug utilization review, the processing of drug prior authorization requests, the adjudication of appeals and grievances related to prescription drug coverage, contracting with network pharmacies and controlling the cost of covered prescription drugs (A.R.S. § 20-3321).
There is no anticipated fiscal impact to the state General Fund associated with this legislation.
Provisions
1. Requires a health care insurer that provides pharmacy benefits or a pharmacy benefits manager that administers pharmacy benefits for a health care insurer, when calculating an enrollee's contribution to any out-of-pocket maximum, deductible, copayment, coinsurance or other applicable cost-sharing requirement, to include any cost-sharing amount paid by either the enrollee or another person on behalf of the enrollee for a prescription drug that is either:
a) without a generic equivalent; or
b) with a generic equivalent when the enrollee has obtained access to the prescription drug through prior authorization, a step therapy protocol or a health care insurer's exceptions and appeals process.
2. Defines a generic equivalent as a drug that has an identical amount of the same active chemical ingredients in the same dosage form, that meets applicable standards of strength, quality and purity, and that, if administered in the same amounts, will provide comparable therapeutic effects.
3. Excludes from generic equivalent a drug that is listed by the U.S. Food and Drug Administration (U.S. FDA) as having unresolved bioequivalent concerns according to the U.S. FDA's most recent publication of approved drug products with therapeutic equivalence evaluations.
4. Defines a health care insurer as a disability insurer, group disability insurer, blanket disability insurer, health care services organization, hospital service corporation, medical service corporation or a hospital, medical, dental and optometric service corporation.
5. Becomes effective on January 1, 2020.
Amendments Adopted by the Finance Committee
· Adds specific conditions for the inclusion of cost-sharing amounts.
Amendments Adopted by Committee of the Whole
1. Changes the AB-rated generic equivalent to a generic equivalent.
2. Defines a generic equivalent.
3. Removes the option of a clinical pathway.
House Action Senate Action
HHS 2/21/19 DPA/SE 7-1-1-0 HHS 3/20/19 DP 7-0-1
3rd Read 3/4/19 58-0-2 FIN 3/27/19 DPA 7-0-3
Prepared by Senate Research
April 8, 2019
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