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ARIZONA STATE SENATE
Fifty-Fourth Legislature, First Regular Session
pharmacy benefit managers; pharmacy benefits
Purpose
Establishes pharmacy benefit manager (PBM) duties related to drug information and maximum allowable cost (MAC) pricing. Precludes PBMs and group health plan sponsors (sponsors) from prohibiting specified retail pharmacies from dispensing 90-day fills of prescriptions and delivering prescriptions under certain circumstances.
Background
A PBM is 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: 1) the processing and payment of claims for prescription drugs; 2) the performance of drug utilization review; 3) processing of drug prior authorization requests; 4) the adjudication of appeals or grievances related to prescription drug coverage; 5) contracting with network pharmacies; and 6) controlling the cost of covered prescription drugs (A.R.S. § 20-3321).
PBMs are prohibited from: 1) prohibiting a pharmacist or pharmacy from providing an insured individual information on the amount of the insured's cost share for the insured prescription drug and the clinical efficacy of a more affordable alternative drug if one is available; 2) penalizing a pharmacy or pharmacist for disclosing such information to an insured or for selling to an insured a more affordable alternative if one is available; and 3) requiring a pharmacist or pharmacy to change or collect a copayment from an insured if it exceeds the total submitted charges by the network pharmacy (A.R.S. § 44-1752).
There is no anticipated fiscal impact to the state General Fund associated with this legislation.
Provisions
1. Requires a PBM to:
a) update the price and drug information for each list that the PBM maintains every seven business days;
b) make the sources used to determine MAC pricing available to each network pharmacy at the beginning of the term of a contract, on renewal of a contract and at least once annually during the term of a contract;
c) establish a process by which a network pharmacy can appeal its reimbursement for a drug subject to MAC pricing; and
d) allow a pharmacy services administrative organization that contracts with a PBM to file an appeal of a drug on behalf of the organization's contracted pharmacies.
2. Specifies that all new and existing contracts between a PBM and licensed pharmacy must comply with prescribed requirements beginning on January 1, 2020.
3. Precludes a plan sponsor or PBM from prohibiting an in-network retail pharmacy from dispensing a 90-day fill of a prescription medication pursuant to Board of Pharmacy rules and guidance if:
a) a 90-day fill of that medication is allowed by the sponsor's pharmacy benefit at any retail pharmacy and the retail pharmacy agrees to the reimbursement rate and the contractual requirements required by the sponsor or PBM; or
b) a 90-day fill is required for that medication by the plan sponsor's pharmacy benefit and the retail pharmacy agrees to the reimbursement rate and the contractual requirements required by the plan sponsor or pharmacy benefit manager.
4. Specifies that the 90-day fill exceptions do not apply to:
a) dispensing schedule II or III controlled substances; and
b) the Arizona Health Care Cost Containment System Administration (AHCCCS) and its contractors.
5. Precludes a plan sponsor or PBM from prohibiting a retail pharmacy from offering as an ancillary service of a pharmacy within the terms of the contract:
a) the limited delivery of prescription drugs to a patient by mail or common carrier to a patient; and
b) the hand delivery of prescription drugs to a patient by an employee or contractor of the pharmacy.
6. Prohibits a pharmacy from charging the plan sponsor or PBM for the delivery of a prescription to a patient unless specifically agreed upon by the sponsor or PBM.
7. Requires a pharmacy to disclose to the patient any fee that will be charged to the patient for the delivery of a prescription drug, including that the fee may not be reimbursable by the sponsor or PBM.
8. Specifies that requirements related to the delivery of prescription drugs do not apply to AHCCCS and its contractors.
9. Defines plan sponsor as an employer or organization that offers a group health plan to its employees or members.
10. Defines list as the list of drugs for which a PBM has established a MAC.
11. Defines MAC as the maximum amount that a PBM will reimburse a pharmacy for the costs of a multisource drug and excludes the dispensing fee for the drug.
12. Makes technical and conforming changes.
13. Becomes effective on the general effective date, with a delayed effective date as noted.
House Action
HHS 1/31/19 DPA 9-0-0-0
3rd Read 2/14/19 60-0-0
Prepared by Senate Research
March 11, 2019
CRS/AG/kja