Regular Session 2017-2018 House Bill 1800 P.N. 3681

SENATE AMENDED

PRIOR PRINTER'S NO. 3224

PRINTER'S NO. 3681

THE GENERAL ASSEMBLY OF PENNSYLVANIA

HOUSE BILL

No.

1800

Session of

2018

INTRODUCED BY NELSON, PICKETT, LONGIETTI, WARREN, V. BROWN,

DRISCOLL, MARSHALL, DIAMOND, BIZZARRO, BAKER, HENNESSEY,

MASSER, BOBACK, SAYLOR, KAUFFMAN, MARSICO, PHILLIPS-HILL,

CORBIN, NESBIT, ZIMMERMAN, WARD, WATSON, MILNE, FARRY, FRITZ,

WALSH, ROE, DUNBAR, EVANKOVICH, MURT, BERNSTINE, CHARLTON,

COMITTA, REESE, DALEY, KAUFER, GROVE, B. MILLER, DiGIROLAMO,

ROTHMAN, COOK, DELOZIER, GABLER, KLUNK, DeLUCA, BOYLE,

SIMMONS, HELM AND J. McNEILL, APRIL 2, 2018

SENATOR WHITE, BANKING AND INSURANCE, IN SENATE, AS AMENDED,

JUNE 13, 2018

AN ACT

Amending Title 40 (Insurance) of the Pennsylvania Consolidated

Statutes, in regulation of insurers and related persons

generally, providing for medication synchronization.

The General Assembly of the Commonwealth of Pennsylvania

hereby enacts as follows:

Section 1. Part II of Title 40 of the Pennsylvania

Consolidated Statutes is amended by adding a chapter to read:

CHAPTER 39

MEDICATION SYNCHRONIZATION

Sec.

3901. Definitions.

3902. Prorated daily cost-sharing rate.

3903. Denial of coverage.

3904. Certain payment structures prohibited.

3905. Application of chapter.

§ 3901. Definitions.

The following words and phrases when used in this chapter

shall have the meanings given to them in this section unless the

context clearly indicates otherwise:

"Health insurance plan POLICY ." A AN INDIVIDUAL OR GROUP

policy, subscriber contract, certificate or plan issued by an

insurer that provides medical or health care coverage. The term

does not include any of the following:

(1) An accident only policy.

(2) A credit only policy.

(3) A long-term care or disability income policy.

(4) A specified disease policy.

(5) A Medicare supplement policy.

(6) A TRICARE policy, including a Civilian Health and

Medical Program of the Uniformed Services (CHAMPUS)

supplement policy.

(7) A fixed indemnity policy.

(8) A dental only policy.

(9) A vision only policy.

(10) A workers' compensation policy.

(11) An automobile medical payment policy.

(12) Another similar policy providing for limited

benefits.

"Insurer." An entity licensed by the department with

accident and health authority to issue a policy, subscriber

contract, certificate or plan that provides medical or health

care coverage HEALTH INSURANCE POLICY that is offered or

governed under any of the following:

(1) The act of May 17, 1921 (P.L.682, No.284), known as

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The Insurance Company Law of 1921, including section 630 and

Article XXIV of that act.

(2) The act of December 29, 1972 (P.L.1701, No.364),

known as the Health Maintenance Organization Act.

(3) Chapter 61 (relating to hospital plan corporations)

or 63 (relating to professional health services plan

corporations).

"Maintenance medication." A medication prescribed for a

chronic, long-term condition and taken on a regular, recurring

basis.

"Medication synchronization." The coordination of

prescription drug filling or refilling by a pharmacy or

dispensing physician for a program participant HEALTH INSURANCE

ENROLLEE taking two or more maintenance medications for the

purpose of improving medication adherence.

"Pharmacy." Every place properly issued a permit by the

State Board of Pharmacy where drugs, devices and diagnostic

agents for human or animal consumption are stored, dispensed or

compounded, excluding offices or facilities of veterinarians

licensed by the State Board of Veterinary Medical Examiners. The

following shall apply:

(1) The term shall not include the operations of a

manufacturer or distributor as defined in the act of April

14, 1972 (P.L.233, No.64), known as The Controlled Substance,

Drug, Device and Cosmetic Act.

(2) In an institution, the term shall refer to the

organized pharmacy service in the institution under the

direct supervision of a licensed pharmacist. AS DEFINED IN

SECTION 2 OF THE ACT OF SEPTEMBER 27, 1961 (P.L.1700,

NO.699), KNOWN AS THE PHARMACY ACT.

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§ 3902. Prorated daily cost-sharing rate.

A health insurance plan POLICY shall permit and apply a

prorated daily cost-sharing rate to prescription drugs

MAINTENANCE MEDICATIONS that are dispensed by a pharmacy as a

partial supply if the pharmacist or prescriber determines the

fill or refill to be in the best interest of the patient and the

patient requests or agrees to a partial supply for the purpose

of medication synchronization. The fill or refill under this

section shall be limited to three times per year for each

maintenance medication for a covered individual. For each

clinically necessary synchronization thereafter, approval may be

required at the discretion of the health insurance plan POLICY .

§ 3903. Denial of coverage.

(a) Partial supply.-- No individual or group health insurance

plan A HEALTH INSURANCE POLICY providing prescription drug

coverage shall MAY NOT deny coverage for the dispensing of a

MAINTENANCE medication that is dispensed by a network pharmacy

on the basis that the dispensing is for a partial supply if the

prescriber or pharmacist determines the fill or refill to be in

the best interest of the patient and the patient requests or

agrees to a partial supply for the purpose of medication

synchronization.

(b) Denial codes.--The individual or group health insurance

plan HEALTH INSURANCE POLICY shall accept early refill and short

fill PARTIAL SUPPLY requests for MAINTENANCE medications

dispensed for the purpose of medication synchronization using

the submission clarification and message codes as adopted by the

National Council for Prescription Drug Programs or alternative

codes provided by the individual or group health insurance plan

HEALTH INSURANCE POLICY .

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individual or group health insurance plan MAY PROHIBIT A HEALTH

INSURANCE POLICY from using other methods to comply with this

chapter.

§ 3904. Certain payment structures prohibited.

(a) Prorated dispensing fees.-- No individual or group health

insurance plan A HEALTH INSURANCE PLAN providing prescription

drug coverage shall MAY NOT use payment structures incorporating

prorated dispensing fees.

(b) Full payment.--Dispensing fees for partially filled A

PARTIAL SUPPLY or refilled prescriptions shall be paid in full

for each maintenance medication dispensed, regardless of any

prorated copay for the beneficiary or fee paid for alignment

services.

§ 3905. Application of chapter.

(A) PRESCRIPTION DRUGS.-- This chapter does not apply to

prescription drugs that are:

(1) in -unit of use UNIT-OF-USE packaging for which

medication synchronization is not possible; or

(2) controlled substances classified in Schedule II

under section 4(2) of the act of April 14, 1972 (P.L.233,

No.64), known as The Controlled Substance, Drug, Device and

Cosmetic Act.

(B) HEALTH INSURANCE POLICIES.--THIS CHAPTER SHALL APPLY TO

HEALTH INSURANCE POLICIES AS FOLLOWS:

(1) FOR A HEALTH INSURANCE POLICY FOR WHICH EITHER RATES

OR FORMS ARE REQUIRED TO BE FILED WITH THE FEDERAL GOVERNMENT

OR THE INSURANCE DEPARTMENT, THIS CHAPTER SHALL APPLY TO A

HEALTH INSURANCE POLICY FOR WHICH A FORM OR RATE IS FIRST

PERMITTED TO BE USED ON OR AFTER THE EFFECTIVE DATE OF THIS

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SECTION.

(2) FOR A HEALTH INSURANCE POLICY FOR WHICH NEITHER

RATES NOR FORMS ARE REQUIRED TO BE FILED WITH THE FEDERAL

GOVERNMENT OR THE INSURANCE DEPARTMENT, THIS CHAPTER SHALL

APPLY TO A HEALTH INSURANCE POLICY ISSUED OR RENEWED ON OR

AFTER THE EFFECTIVE DATE OF THIS SECTION.

Section 2. This act shall take effect in 365 days.

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