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AB-2863 Health care coverage: prescriptions.(2017-2018)

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Date Published: 04/11/2018 09:00 PM
AB2863:v97#DOCUMENT

Revised  April 18, 2018
Amended  IN  Assembly  April 11, 2018
Amended  IN  Assembly  March 23, 2018

CALIFORNIA LEGISLATURE— 2017–2018 REGULAR SESSION

Assembly Bill No. 2863


Introduced by Assembly Member Nazarian
(Coauthors: Assembly Members Burke and Wood)

February 16, 2018


An act to add Section 4445 to the Business and Professions Code, relating to pharmacy. Section 1367.47 to the Health and Safety Code, and to add Section 10123.65 to the Insurance Code, relating to health care coverage.


LEGISLATIVE COUNSEL'S DIGEST


AB 2863, as amended, Nazarian. Pharmacy: prescriptions: pharmacy benefit manager: cost. Health care coverage: prescriptions.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan or health insurer that covers outpatient prescription drug benefits to provide coverage for specified prescription drugs, and requires cost sharing for outpatient prescription drugs to be reasonable so as to allow access to medically necessary outpatient prescription drugs.
This bill would limit the amount a health care service plan, health insurer, or pharmacy benefit manager may require an enrollee or insured to pay at the point of sale for a covered prescription to the lesser of the applicable cost-sharing amount or the retail price. The bill would prohibit a health care service plan, health insurer, or pharmacy benefit manager from requiring a pharmacy to charge or collect a copayment from an enrollee or insured that exceeds the total submitted charges by the network pharmacy. The bill would require the amount paid for a prescription to be applied to the enrollee’s or insured’s deductible and out-of-pocket maximum if the enrollee or insured pays the retail price.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.

The Pharmacy Law provides for the licensing and regulation of the practice of pharmacy under the jurisdiction of the California State Board of Pharmacy within the Department of Consumer Affairs. Existing law establishes requirements for prescriptions, including specific requirements for the substitution of drugs on filling a prescription order.

Existing law requires a pharmacy benefit manager that reimburses a contracting pharmacy for a drug on a maximum allowable cost basis to include information identifying any national drug pricing compendia or other data sources used to determine the maximum allowable cost for the drugs on a maximum allowable cost list and to provide for an appeal process for the contracting pharmacy in any contract entered into or renewed on or after January 1, 2016. Existing law requires a pharmacy benefit manager to make available to a contracting pharmacy, upon request, the most up-to-date maximum allowable cost list or lists used by the pharmacy benefit manager for patients served by the pharmacy.

This bill would prohibit a contract between a health carrier or a pharmacy benefit manager and a pharmacy from penalizing a pharmacy’s disclosure of the cost of the prescription medication or the availability of alternative medications or less costly alternative methods of purchasing a medication to a health benefit plan beneficiary. The bill would limit the amount a health carrier or pharmacy benefit manager may require a health benefit plan beneficiary to pay at the point of sale for a covered prescription medication to the lesser of the applicable cost-sharing amount or the amount the beneficiary would pay without using a health benefit plan. The bill would prohibit a health carrier or pharmacy benefit manager from requiring a pharmacy to charge or collect a copayment from a beneficiary that exceeds the total submitted charges by the network pharmacy. The bill would require the amount paid for a prescription to be applied to the beneficiary’s deductible and out-of-pocket maximum if the beneficiary opts to pay the cash price.

Vote: MAJORITY   Appropriation: NO   Fiscal Committee: NOYES   Local Program: NOYES  

The people of the State of California do enact as follows:


SECTION 1.

 Section 1367.47 is added to the Health and Safety Code, to read:

1367.47.
 (a) The maximum amount a health care service plan or pharmacy benefit manager, as defined in Section 4430 of the Business and Professions Code, may require an enrollee to pay at the point of sale for a covered prescription medication is the lesser of the following:
(1) The applicable cost-sharing amount for the prescription medication.
(2) The retail price.
(b) A health care service plan or pharmacy benefit manager shall not require a pharmacist or pharmacy to charge or collect from an enrollee a copayment that exceeds the total submitted charges by the network pharmacy. If an enrollee pays the retail price instead of paying the cost-sharing amount for the prescription medication, that amount shall be applied to the enrollee’s deductible and out-of-pocket maximum in the same manner as if the enrollee had purchased the prescription medication by paying the cost-sharing amount.

SEC. 2.

 Section 10123.65 is added to the Insurance Code, to read:

10123.65.
 (a) The maximum amount a health insurer or pharmacy benefit manager, as defined in Section 4430 of the Business and Professions Code, may require an insured to pay at the point of sale for a covered prescription medication is the lesser of the following:
(1) The applicable cost-sharing amount for the prescription medication.
(2) The retail price.
(b) A health insurer or pharmacy benefit manager shall not require a pharmacist or pharmacy to charge or collect from an insured a copayment that exceeds the total submitted charges by the network pharmacy. If an insured pays the retail price instead of paying the cost-sharing amount for the prescription medication, that amount shall be applied to the insured’s deductible and out-of-pocket maximum in the same manner as if the insured had purchased the prescription medication by paying the cost-sharing amount.

SEC. 3.

 No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII B of the California Constitution.
SECTION 1.Section 4445 is added to the Business and Professions Code, to read:
4445.

(a)A contract entered into or renewed on or after January 1, 2019, between a health carrier or a pharmacy benefit manager and a pharmacist or pharmacy may not penalize a pharmacist’s or pharmacy’s disclosure of any of the following information to a health benefit plan beneficiary purchasing prescription medication:

(1)The cost of the prescription medication to the beneficiary.

(2)The availability of any therapeutically equivalent alternative medications or alternative methods of purchasing the prescription medication that are less expensive than the cost of the prescription medication to the beneficiary, including, but not limited to, paying the cash price.

(b)The maximum amount a health carrier or pharmacy benefit manager may require a health benefit plan beneficiary to pay at the point of sale for a covered prescription medication is the lesser of the following:

(1)The applicable cost-sharing amount for the prescription medication.

(2)The amount the beneficiary would pay for the prescription medication if the beneficiary purchased the prescription medication without using a health benefit plan or any other source of prescription medication benefits or discounts.

(c)A health carrier or pharmacy benefit manager shall not require a pharmacist or pharmacy to charge or collect from a beneficiary a copayment that exceeds the total submitted charges by the network pharmacy. If a beneficiary pays the amount specified in paragraph (2) of subdivision (b) instead of paying the cost-sharing amount for the prescription medication, that amount shall be applied to the beneficiary’s deductible and out-of-pocket maximum in the same manner as if the beneficiary had purchased the prescription medication by paying the cost-sharing amount.

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REVISIONS:
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