Missouri HB 1165: Modifies provisions relating to pharmacy benefits

Bill Text

FIRST REGULAR SESSION
HOUSE BILL NO. 1165
100TH GENERAL ASSEMBLY
INTRODUCED BY REPRESENTATIVE MORRIS (140).
2319H.01I DANA RADEMAN MILLER, Chief Clerk
AN ACT
To repeal sections 376.387 and 376.388, RSMo, and to enact in lieu thereof five new sections
relating to pharmacy benefits, with a penalty provision.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Sections 376.387 and 376.388, RSMo, are repealed and five new sections
2 enacted in lieu thereof, to be known as sections 376.387, 376.388, 376.393, 376.2062, and
3 376.2066, to read as follows:
376.387. 1. For purposes of this section, the following terms shall mean:
2 (1) "Covered person", the same meaning as such term is defined in section 376.1257;
3 (2) "Health benefit plan", the same meaning as such term is defined in section 376.1350;
4 (3) "Health carrier" or "carrier", the same meaning as such term is defined in
5 section 376.1350;
6 (4) "Pharmacy", the same meaning as such term is defined in chapter 338;
7 (5) "Pharmacy benefits manager", the same meaning as such term is defined in section
8 376.388.
9 2. No pharmacy benefits manager shall include a provision in a contract entered into or
10 modified on or after August 28, 2018, with a pharmacy or pharmacist that requires a covered
11 person to make a payment for a prescription drug at the point of sale in an amount that exceeds
12 the lesser of:
13 (1) The copayment amount as required under the health benefit plan; or
14 (2) The amount an individual would pay for a prescription if that individual paid with
15 cash.
EXPLANATION — Matter enclosed in bold-faced brackets [thus] in the above bill is not enacted and is intended
to be omitted from the law. Matter in bold-face type in the above bill is proposed language.

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16 3. A pharmacy or pharmacist shall have the right to provide to a covered person
17 information regarding the amount of the covered person's cost share for a prescription drug, the
18 covered person's cost of an alternative drug, and the covered person's cost of the drug without
19 adjudicating the claim through the pharmacy benefits manager. Neither a pharmacy nor a
20 pharmacist shall be proscribed by a pharmacy benefits manager from discussing any such
21 information or from selling a more affordable alternative to the covered person.
22 4. No pharmacy benefits manager shall, directly or indirectly, charge or hold a
23 pharmacist or pharmacy responsible for any fee amount related to a claim that is not known at
24 the time of the claim's adjudication, unless the amount is a result of improperly paid claims or
25 charges for administering a health benefit plan.
26 5. A pharmacy benefits manager shall notify in writing any health carrier or
27 pharmacy with which it contracts if the pharmacy benefits manager has a potential conflict
28 of interest including, but not limited to, any commonality of ownership or any other
29 relationship, financial or otherwise, between the pharmacy benefits manager and any other
30 health carrier or pharmacy with which the pharmacy benefits manager contracts.
31 6. This section shall not apply with respect to [claims under] Medicare Part D, or any
32 other plan administered or regulated solely under federal law, and to the extent this section may
33 be preempted under the Employee Retirement Income Security Act of 1974 for self-funded
34 employer-sponsored health benefit plans.
35 [6.] 7. The department of insurance, financial institutions and professional registration
36 shall enforce this section.
376.388. 1. As used in this section, unless the context requires otherwise, the following
2 terms shall mean:
3 (1) "Contracted pharmacy" [or "pharmacy"], a pharmacy located in Missouri
4 participating in the network of a pharmacy benefits manager through a direct or indirect contract;
5 (2) "Health carrier", an entity subject to the insurance laws and regulations of this state
6 that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of
7 the costs of health care services, including a sickness and accident insurance company, a health
8 maintenance organization, a nonprofit hospital and health service corporation, or any other entity
9 providing a plan of health insurance, health benefits, or health services, except that such plan
10 shall not include any coverage pursuant to a liability insurance policy, workers' compensation
11 insurance policy, or medical payments insurance issued as a supplement to a liability policy;
12 (3) "Maximum allowable cost", the per-unit amount that a pharmacy benefits manager
13 reimburses a pharmacist for a prescription drug, excluding a dispensing or professional fee;
14 (4) "Maximum allowable cost list" or "MAC list", a listing of drug products that meet
15 the standard described in this section;

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16 (5) "Pharmacy", as such term is defined in chapter 338;
17 (6) "Pharmacy benefits manager", an entity that contracts with pharma