PRINTER'S NO. 3224
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 AND KLUNK, APRIL 2, 2018
REFERRED TO COMMITTEE ON INSURANCE, APRIL 2, 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.
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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." A 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 that is offered or governed under any of the
following:
(1) The act of May 17, 1921 (P.L.682, No.284), known as
The Insurance Company Law of 1921, including section 630 and
Article XXIV of that act.
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(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 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.
§ 3902. Prorated daily cost-sharing rate.
A health insurance plan shall permit and apply a prorated
daily cost-sharing rate to prescription drugs that are dispensed
by a pharmacy as a partial supply if the pharmacist or
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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.
§ 3903. Denial of coverage.
(a) Partial supply.--No individual or group health insurance
plan providing prescription drug coverage shall deny coverage
for the dispensing of a 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 shall accept early refill and short fill requests for
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.
(c) Compliance.--Nothing in this chapter shall prohibit the
individual or group health insurance plan 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 providing prescription drug coverage shall use
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payment structures incorporating prorated dispensing fees.
(b) Full payment.--Dispensing fees for partially filled 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.
This chapter does not apply to prescription drugs that are:
(1) in -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.
Section 2. This act shall take effect in 365 days.
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