PRINTER'S NO. 1806
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
1630
Session of
2021
INTRODUCED BY FRITZ, HEFFLEY, RYAN, BOBACK, RADER, HAMM,
MILLARD, CIRESI, PEIFER, DeLUCA AND GROVE, JUNE 15, 2021
REFERRED TO COMMITTEE ON HEALTH, JUNE 15, 2021
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 pharmacy benefits manager audit and
obligations.
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 449.2. Pharmacy Benefits Manager Audit and
Obligations.--(a) The Department of the Auditor General may
conduct an audit and review of a pharmacy benefits manager that
provides pharmacy benefits management to a medical assistance
managed care organization under contract with the department.
The Department of the Auditor General may review all previous
audits completed by the department and shall have access to all
documents it deems necessary to complete the review and audit.
(b) Any information disclosed or produced by a pharmacy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
benefits manager or a medical assistance managed care
organization for the use of the department or the Department of
the Auditor General under this section shall not be subject to
the act of February 14, 2008 (P.L.6, No.3), known as the "Right-
to-Know Law."
(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 (49 Stat. 620, 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 by a 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
20210HB1630PN1806 - 2 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
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 any affiliated ownership of a medical assistance
managed care organization that performs pharmacy benefits
management.
Section 2. This act shall take effect in 60 days.
20210HB1630PN1806 - 3 -
1
2
3
4
5
6
7
8
9
10
11