LC001 01 -- S S T A T E O F R H O D E I S L A N D IN GENERAL ASSEMBLY JANUARY SESSION, A.D. 01 A N A C T RELATING TO INSURANCE -- HEALTH INSURANCE -- PRESCRIPTION DRUG BENEFITS Introduced By: Senators Walaska, McCaffrey, Ciccone, and Cote Date Introduced: February, 01 Referred To: Senate Health & Human Services It is enacted by the General Assembly as follows: 1 1 1 1 1 1 1 1 SECTION 1. Chapter -1 of the General Laws entitled "Accident and Sickness Insurance Policies" is hereby amended by adding thereto the following section: -1-.. Pharmacy benefit manager requirements with respect to multi-source (1) "Maximum allowable cost" or "MAC" means the maximum amount that a pharmacy () "Nationally available" means that there is an adequate supply available from regional () "Pharmacy benefit manager" or "PBM" means an entity doing business in this state (i) Include in such contracts, the sources generally used to determine MAC pricing and a requirement to update pricing information on the MAC list at least every ten () calendar days; pricing or modify MAC rates within ten () calendar days when such drugs do not meet the
1 1 1 1 1 1 1 1 0 1 0 1 () PBM requirements for inclusion of products on a list of drugs subject to MAC pricing. In order to place a particular prescription drug on a MAC list, the PBM must, at a organization (PSAO) shall include a process to appeal investigate, and resolve disputes regarding (i) The right to appeal shall be limited to fifteen (1) days following the initial claim; (ii) The appeal shall be investigated and resolved within fifteen (1) days following receipt of the appeal; process; (iv) If the appeal is denied, the PBM shall provide the reason for the denial and identify SECTION. Chapter -1 of the General Laws entitled "Nonprofit Hospital Service Corporations" is hereby amended by adding thereto the following section: -1-.1. Pharmacy benefit manager requirements with respect to multi-source (1) "Maximum allowable cost" or "MAC" means the maximum amount that a pharmacy () "Nationally available" means that there is an adequate supply available from regional () "Pharmacy benefit manager" or "PBM" means an entity doing business in this state LC001 - Page of
1 1 1 1 1 1 1 1 0 1 0 1 (i) Include in such contracts, the sources generally used to determine MAC pricing and a requirement to update pricing information on the MAC list at least every ten () calendar days; pricing or modify MAC rates within ten () calendar days when such drugs do not meet the () PBM requirements for inclusion of products on a list of drugs subject to MAC pricing. In order to place a particular prescription drug on a MAC list, the PBM must, at a organization (PSAO) shall include a process to appeal, investigate, and resolve disputes regarding (i) The right to appeal shall be limited to fifteen (1) days following the initial claim; (ii) The appeal shall be investigated and resolved within fifteen (1) days following receipt of the appeal: process: (iv) If the appeal is denied, the PBM shall provide the reason for the denial and identify LC001 - Page of
1 1 1 1 1 1 1 1 0 1 0 1 SECTION. Chapter -0 of the General Laws entitled "Nonprofit Medical Service Corporations" is hereby amended by adding thereto the following section: -0-.1. Pharmacy benefit manager requirements with respect to multi-source (1) "Maximum allowable cost" or "MAC' means the maximum amount that a pharmacy () "Nationally available" means that there is an adequate supply available from regional () "Pharmacy benefit manager" or "PBM" means an entity doing business in this state (i) Include in such contracts, the sources generally used to determine MAC pricing and a requirement to update pricing information on the MAC list at least every ten () calendar days; pricing or modify MAC rates within ten () calendar days when such drugs do not meet the () PBM requirements for inclusion of products on a list of drugs subject to MAC pricing. In order to place a particular prescription drug on a MAC list, the PBM must. at a organization (PSAO) shall include a process to appeal, investigate, and resolve disputes regarding (i) The right to appeal shall be limited to fifteen (1) days following the initial claim; LC001 - Page of
1 1 1 1 1 1 1 1 0 1 0 1 (ii) The appeal shall be investigated and resolved within fifteen (1) days following receipt of the appeal: process; (iv) If the appeal is denied. the PBM shall provide the reason for the denial and identify SECTION. Chapter -0.1 of the General Laws entitled "Nonprofit Dental Service Corporations" is hereby amended by adding thereto the following section: -0.1-1.1. Pharmacy benefit manager requirements with respect to multi-source (1) "Maximum allowable cost" or "MAC" means the maximum amount that a pharmacy () "Nationally available" means that there is an adequate supply available from regional () "Pharmacy benefit manager" or "PBM" means an entity doing business in this state (i) Include in such contracts, the sources generally used to determine MAC pricing and a requirement to update pricing information on the MAC list at least every ten () calendar days; pricing or modify MAC rates within ten () calendar days when such drugs do not meet the () PBM requirements for inclusion of products on a list of drugs subject to MAC pricing. In order to place a particular prescription drug on a MAC list, the PBM must, at a LC001 - Page of
1 1 1 1 1 1 1 1 0 1 0 1 organization (PSAO) shall include a process to appeal, investigate, and resolve disputes regarding (i) The right to appeal shall be limited to fifteen (1) days following the initial claim; (ii) The appeal shall be investigated and resolved within fifteen (1) days following receipt of the appeal; process; (iv) If the appeal is denied, the PBM shall provide the reason for the denial and identify SECTION. Chapter -1 of the General Laws entitled "Health Maintenance Organizations" is hereby amended by adding thereto the following section: -1-.1. Pharmacy benefit manager requirements with respect to multi-source (1) "Maximum allowable cost" or "MAC" means the maximum amount that a pharmacy () "Nationally available" means that there is an adequate supply available from regional () "Pharmacy benefit manager" or "PBM" means an entity doing business in this state (i) Include in such contracts. the sources generally used to determine MAC pricing and a requirement to update pricing information on the MAC list at least every ten () calendar days; LC001 - Page of
1 1 1 1 1 1 1 1 0 1 pricing or modify MAC rates within ten () calendar days when such drugs do not meet the () PBM requirements for inclusion of products on a list of drugs subject to MAC pricing. In order to place a particular prescription drug on a MAC list, the PBM must, at a organization (PSAO) shall include a process to appeal, investigate, and resolve disputes regarding (i) The right to appeal shall be limited to fifteen (1) days following the initial claim: (ii) The appeal shall be investigated and resolved within fifteen (1) days following receipt of the appeal; process; (iv) If the appeal is denied, the PBM shall provide the reason for the denial and identify SECTION. This act shall take effect on September 0, 01. LC001 LC001 - Page of
EXPLANATION BY THE LEGISLATIVE COUNCIL OF A N A C T RELATING TO INSURANCE -- HEALTH INSURANCE -- PRESCRIPTION DRUG BENEFITS *** 1 This act would regulate business relationships among pharmacy services providers, group health insurers, and health service organizations by providing department of health oversight. This act would take effect on September 0, 01. LC001 LC001 - Page of