Bill Text: FL S1014 | 2014 | Regular Session | Comm Sub

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Pharmacy Benefit Managers

Spectrum: Slight Partisan Bill (? 2-1)

Status: (Failed) 2014-05-02 - Died in Appropriations [S1014 Detail]

Download: Florida-2014-S1014-Comm_Sub.html

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       Florida Senate - 2014                             CS for SB 1014
       
       
        
       By the Committee on Health Policy; and Senator Garcia
       
       
       
       
       
       588-02829-14                                          20141014c1
    1                        A bill to be entitled                      
    2         An act relating to pharmacy benefit managers; creating
    3         s. 465.1862, F.S.; defining terms; specifying contract
    4         terms that must be included in a contract between a
    5         pharmacy benefit manager and a pharmacy; providing
    6         restrictions on the inclusion of prescription drugs on
    7         a list that specifies the maximum allowable cost for
    8         such drugs; requiring the pharmacy benefit manager to
    9         disclose certain information to a plan sponsor;
   10         requiring a contract between a pharmacy benefit
   11         manager and a pharmacy to include an appeal process;
   12         providing an effective date.
   13          
   14  Be It Enacted by the Legislature of the State of Florida:
   15  
   16         Section 1. Section 465.1862, Florida Statutes, is created
   17  to read:
   18         465.1862 Pharmacy benefit managers.—
   19         (1) As used in this section, the term:
   20         (a) “Maximum allowable cost” (MAC) means the upper limit or
   21  maximum amount that an insurance or managed care plan will pay
   22  for generic, or brand-name drugs that have generic versions
   23  available, which are included on a PBM-generated list of
   24  products.
   25         (b) “Plan sponsor” means an employer, insurer, managed care
   26  organization, prepaid limited health service organization,
   27  third-party administrator, or other entity contracting for
   28  pharmacy benefit manager services.
   29         (c) “Pharmacy benefit manager” (PBM) means a person,
   30  business, or other entity that provides administrative services
   31  related to processing and paying prescription claims for
   32  pharmacy benefit and coverage programs. Such services may
   33  include contracting with a pharmacy or network of pharmacies;
   34  establishing payment levels for provider pharmacies; negotiating
   35  discounts and rebate arrangements with drug manufacturers;
   36  developing and managing prescription formularies, preferred drug
   37  lists, and prior authorization programs; assuring audit
   38  compliance; and providing management reports.
   39         (2) A contract between a pharmacy benefit manager and a
   40  pharmacy which includes MAC pricing must require the pharmacy
   41  benefit manager to:
   42         (a) Update the MAC pricing information at least every 7
   43  calendar days and establish a reasonable process for the prompt
   44  notification of such pricing updates to network pharmacies; and
   45         (b) Maintain a procedure to eliminate products from the
   46  list or modify the MAC pricing in a timely fashion in order to
   47  remain consistent with pricing changes in the marketplace.
   48         (3) In order to place a particular prescription drug on a
   49  MAC list, the pharmacy benefit manager must, at a minimum,
   50  ensure that the drug has at least three or more nationally
   51  available, therapeutically equivalent, multiple-source generic
   52  drugs which:
   53         (a) Have a significant cost difference;
   54         (b) Are listed as therapeutically and pharmaceutically
   55  equivalent or “A” rated in the United States Food and Drug
   56  Administration’s most recent version of the Orange Book;
   57         (c) Are available for purchase without limitations by all
   58  pharmacies in the state from national or regional wholesalers;
   59  and
   60         (d) Are not obsolete or temporarily unavailable.
   61         (4) The pharmacy benefit manager must disclose the
   62  following to the plan sponsor:
   63         (a) The basis of the methodology and sources used to
   64  establish applicable MAC pricing in the contract between the
   65  pharmacy benefit manager and the plan sponsor. Applicable MAC
   66  lists must be updated and provided to the plan sponsor whenever
   67  there is a change.
   68         (b) Whether the pharmacy benefit manager uses a MAC list
   69  for drugs dispensed at retail but does not use a MAC list for
   70  drugs dispensed by mail order in the contract between the
   71  pharmacy benefit manager and the plan sponsor or within 21
   72  business days after implementation of the practice.
   73         (c) Whether the pharmacy benefit manager is using the
   74  identical MAC list with respect to billing the plan sponsor as
   75  it does when reimbursing all network pharmacies. If multiple MAC
   76  lists are used, the pharmacy benefit manager must disclose any
   77  difference between the amount paid to a pharmacy and the amount
   78  charged to the plan sponsor.
   79         (5) All contracts between a pharmacy benefit manager and a
   80  contracted pharmacy must include:
   81         (a) A process for appealing, investigating, and resolving
   82  disputes regarding MAC pricing. The process must:
   83         1. Limit the right to appeal to 90 calendar days following
   84  the initial claim;
   85         2. Investigate and resolve the dispute within 7 days; and
   86         3. Provide the telephone number at which a network pharmacy
   87  may contact the pharmacy benefit manager and speak with an
   88  individual who is responsible for processing appeals.
   89         (b) If the appeal is denied, the pharmacy benefit manager
   90  shall provide the reason for the denial and identify the
   91  national drug code of a drug product that may be purchased by a
   92  contracted pharmacy at a price at or below the MAC.
   93         (c) If an appeal is upheld, the pharmacy benefit manager
   94  shall make an adjustment retroactive to the date the claim was
   95  adjudicated. The pharmacy benefit manager shall make the
   96  adjustment effective for all similarly situated pharmacies in
   97  this state which are within the network.
   98         Section 2. This act shall take effect July 1, 2014.