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PRINTER'S NO. 1099
THE GENERAL ASSEMBLY OF PENNSYLVANIA
SENATE BILL
No.
789
Session of
2019
INTRODUCED BY ARGALL, J. WARD, VOGEL, MARTIN AND PHILLIPS-HILL,
JULY 9, 2019
REFERRED TO HEALTH AND HUMAN SERVICES, JULY 9, 2019
AN ACT
Amending the act of June 13, 1967 (P.L.31, No.21), entitled "An
act to consolidate, editorially revise, and codify the public
welfare laws of the Commonwealth," in public assistance,
providing for use of pharmacy benefits manager by medical
assistance managed care organization.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. The act of June 13, 1967 (P.L.31, No.21), known
as the Human Services Code, is amended by adding a section to
read:
Section 449.1. Use of Pharmacy Benefits Manager by Medical
Assistance Managed Care Organization.--(a) The department shall
prevent a medical assistance managed care organization from
entering into any contract for pharmacy services with a pharmacy
benefits manager if:
(1) the pharmacy benefits manager or a corporate affiliate
of the pharmacy benefits manager has an ownership interest in a
pharmacy providing the pharmacy services; or
(2) the pharmacy providing the pharmacy services has an
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ownership interest in the pharmacy benefits manager or a
corporate affiliate of the pharmacy benefits manager.
(b) A pharmacy benefits manager may not require that a
beneficiary use the services of a specific pharmacy for a
specialty drug.
(c) As used in this section, the following words and phrases
shall have the meanings given to them in this subsection:
"Medical assistance managed care organization" means a
Medicaid managed care organization as defined in section 1903(m)
(1)(a) of the Social Security Act (Public Law 74-271, 42 U.S.C.
ยง 1396b(m)(1)(A)) that is a party to a Medicaid managed care
contract with the department.
"Pharmacy benefits management" means any of the following:
(1) Procurement of prescription drugs at a negotiated
contracted rate for distribution within this Commonwealth to
covered individuals.
(2) Administration or management of prescription drug
benefits provided by a covered entity for the benefit of covered
individuals.
(3) Administration of pharmacy benefits, including:
(i) Operating a mail-service pharmacy.
(ii) Claims processing.
(iii) Managing a retail pharmacy network management.
(iv) Paying claims to pharmacies for prescription drugs
dispensed to covered individuals via retail, specialty or mail-
order pharmacy.
(v) Developing and managing a clinical formulary,
utilization management and quality assurance programs.
(vi) Rebate contracting and administration.
(vii) Managing a patient compliance, therapeutic
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intervention and generic substitution program.
(viii) Operating a disease management program.
(ix) Setting pharmacy reimbursement pricing and
methodologies, including maximum allowable cost, and determining
single or multiple source drugs.
"Pharmacy benefits manager" means a person, business or other
entity that performs pharmacy benefits management. The term
shall include a wholly owned subsidiary of a medical assistance
managed care organization that performs pharmacy benefits
management.
Section 2. This act shall take effect in 60 days.
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