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ARIZONA HOUSE OF REPRESENTATIVESFifty-seventh Legislature First Regular Session |
House: HHS DP 9-0-2-1 |
HB 2208: pharmacists; pharmacies; reimbursement costs; appeals
Sponsor: Representative Bliss, LD 1
Caucus & COW
Overview
Prohibits a pharmacy benefit manager (PBM) from reimbursing a pharmacist or pharmacy under contract with a PBM for a prescription drug or device in an amount that is less than the actual costs paid by the pharmacists or pharmacy. Requires a PBM to pay a professional dispensing fee at a rate not less than the fee-for-service methodology used in the state plan for medical assistance as approved by the Centers for Medicare and Medicaid Services (CMS). Outlines requirements for appeals, defines terms and contains an applicability clause.
History
A PBM means a person, business or other entity that, pursuant to a contract or under an employment relationship with an insurer or other third-party payor, either directly or through an intermediary manages the prescription drug coverage provided by the insurer or other third-party payor, 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 or grievances related to prescription drug coverage, contracting with network pharmacies and controlling the cost of covered prescription drugs (A.R.S. § 20-3321).
A PBM must do all of the following: 1) update the price and drug information for each list that the PBM maintains every seven business days; 2) 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, make available to each network pharmacy the sources used to determine maximum allowable cost pricing; 3) establish a process by which a network pharmacy may appeal its reimbursement for a drug subject to maximum allowable cost pricing; and 4) allow a pharmacy services administrative organization that is contracted with the PBM to file an appeal of a drug on behalf of the organization's contracted pharmacies (A.R.S. § 20-3331).
Provisions
1. Prohibits a PBM from reimbursing a pharmacist or pharmacy that is under contract with the PBM for a prescription drug or device in an amount that is less than the actual cost paid by the pharmacist or pharmacy. (Sec. 1)
2. Exempts a PBM, that uses ingredient cost reimbursement methodology for a prescription drug or device that is identical to the fee-for-service methodology used in the state plan for medical assistance as approved by CMS, from the reimbursement restrictions. (Sec. 1)
3. Prohibits a PBM from including a professional dispensing fee in the amount that is calculated to reimburse a pharmacy for a prescription drug or device. (Sec. 1)
4. Requires a PBM to pay a professional dispensing fee at a rate no less than the fee-for-service methodology used in the state plan for medical assistance as approved by CMS. (Sec. 1)
5. Requires a PBM to include in the contract with each pharmacist or pharmacy a procedure that outlines how a pharmacist or pharmacy may appeal a reimbursement rate that allegedly does not comply with the reimbursement restrictions. (Sec. 1)
6. Requires a pharmacist or pharmacy to file an appeal within seven business days after the date on which the pharmacist or pharmacy was reimbursed for a prescription drug or device. (Sec. 1)
7. Requires a PBM to file its appeal procedures with the Department of Insurance and Financial Institutions (DIFI) and in a manner prescribed by the DIFI. (Sec. 1)
8. Requires DIFI to approve or deny a PBM's appeal procedure. (Sec. 1)
9. Requires the appeal procedure to include a provision that allows an agent of a pharmacist or pharmacy to submit an appeal on behalf of the pharmacist or pharmacy. (Sec. 1)
10. Allows a pharmacist or pharmacy to designate a pharmacy services administrative organization or other agent to file and conduct the appeal. (Sec. 1)
11. Requires a PBM to complete the following within seven business days after the date a pharmacist or pharmacy prevails in an appeal of a reimbursement cost:
a) make the necessary change to the challenged reimbursement or actual cost;
b) provide the pharmacist or pharmacy with the national drug code number for a prescription drug, if the appeal was based on a prescription drug;
c) allow the pharmacist or pharmacy to reverse and rebill the claim;
d) reimburse the pharmacist's or pharmacy's actual cost for the prescription drug or device; and
e) apply the findings of the appeal to the reimbursement rate and actual cost for the prescription drug or device to other similarly situated pharmacists and pharmacies. (Sec. 1)
12. Requires a PBM to provide both of the following no later than seven business days after prevailing on an appeal of a reimbursement cost and the prescription drug or device that was the subject of the appeal is available at a cost that is equal to or less than the challenged reimbursement cost:
a) the name of the national or regional pharmaceutical wholesaler that does business in this state and has the prescription drug or device in stock at a price that is equal to or less than the challenged reimbursement cost; and
b) the national drug code number for the prescription drug or the unique identifier for the device, as applicable. (Sec. 1)
13. Requires a PBM that does not comply with the prohibitions to:
a) adjust the challenged reimbursement cost to an amount that is equal to or greater than the pharmacist's or pharmacy's actual cost; and
b) allow the pharmacist or pharmacy to reverse and rebill each claim that is affected by the inability to obtain the prescription drug or device at a cost that is equal to or less than the challenge reimbursement. (Sec. 1)
14. Defines the following terms:
a) similarly situated pharmacists or pharmacies; and
b) state plan. (Sec. 1)
15. Applies these provisions to contracts that are entered, amended, extended or renewed by December 31, 2025. (Sec. 2)
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19. HB 2208
20. Initials AG/BG Page 0 Caucus & COW
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