H0941B1748A03878 AJB:NLG 11/17/19 #90 A03878
AMENDMENTS TO HOUSE BILL NO. 941
Sponsor: REPRESENTATIVE HEFFLEY
Printer's No. 1748
Amend Bill, page 1, lines 1 through 4, by striking out all of
said lines and inserting
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,
further providing for medical assistance pharmacy services.
Amend Bill, page 1, lines 7 through 17; pages 2 through 6,
lines 1 through 30; page 7, line 1; by striking out all of said
lines on said pages and inserting
Section 1. Section 449 of the act of June 13, 1967 (P.L.31,
No.21), known as the Human Services Code, is amended to read:
Section 449. Medical Assistance Pharmacy Services.--(a) Any
managed care [entity] organization under contract to the
department must contract on an equal basis with any pharmacy
qualified to participate in the Medical Assistance Program that
is willing to comply with the managed care [entity's]
organization's pharmacy payment rates and terms and to adhere to
quality standards established by the managed care [entity]
organization.
(b) The department may conduct an audit or review of an
entity. In the course of an audit or review under this
subsection, a managed care organization utilizing a pharmacy
benefit manager shall provide medical assistance-specific
information from a pharmacy contract or agreement to the
department.
(c) A contract or agreement between an entity and a pharmacy
may not include any of the following:
(1) A confidentiality provision that prohibits the
disclosure of information to the department.
(2) Any provision that restricts the disclosure of
information to or communication with a managed care organization
or the department.
(d) An entity shall maintain records sufficient to disclose,
upon the department's request, information regarding the
provision of pharmacy services eligible for payment by the
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medical assistance program.
(e) Information disclosed or produced by an entity to the
department 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.
(f) If an entity approves a claim for payment under the
medical assistance program, the entity may not retroactively
deny or modify the payment unless any of the following apply:
(1) The claim was fraudulent.
(2) The claim was duplicative of a previously paid claim.
(3) The pharmacy did not dispense the pharmacy service on
the claim.
(g) A managed care organization or pharmacy benefit manager
may not do any of the following:
(1) Mandate that a medical assistance recipient use a
specific pharmacy or other entity if any of the following apply:
(i) The managed care organization or pharmacy benefit
manager has an ownership interest in the pharmacy or other
entity.
(ii) The pharmacy or other entity has an ownership interest
in the managed care organization or pharmacy benefit manager.
(2) Provide an incentive to a medical assistance recipient
to encourage the use of a specific pharmacy.
(h) A pharmacy benefit manager or pharmacy services
administration organization may not do any of the following:
(1) Require that a pharmacist or pharmacy participate in a
network managed by the pharmacy benefit manager or pharmacy
services administration organization as a condition for the
pharmacist or pharmacy to participate in another network managed
by the same pharmacy benefit manager or pharmacy services
administration organization.
(2) A utomatically enroll or disenroll a pharmacist or
pharmacy without cause in a contract or modify an existing
agreement without written agreement of the pharmacist or
pharmacy.
(3) Charge or retain a differential between what is billed
to a managed care organization as a reimbursement for a pharmacy
service and what is paid to pharmacies by the pharmacy benefit
manager or pharmacy services administration organization for the
pharmacy service.
(4) Charge pharmacy transmission fees.
(i) A managed care organization or pharmacy benefit manager
shall provide payment for a pharmacy service that is a covered
benefit if the pharmacy service is performed by a licensed
pharmacist in accordance with all of the following:
(1) The pharmacy service performed is within the scope of
practice of the licensed pharmacist.
(2) The managed care organization or pharmacy benefit
manager would cover the pharmacy service if the pharmacy service
was performed by a physician, an advanced practice registered
nurse or a physician assistant.
(j) As used in this section, the following words and phrases
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shall have the meanings given to them in this subsection:
"Entity" means a pharmacy, pharmacy benefit manager, pharmacy
services administration organization or other entity that
manages, processes, influences the payment for or dispenses
pharmacy services to medical assistance recipients in the
managed care delivery system.
"Pharmacy benefit management" means any of the following:
(1) The procurement of prescription drugs at a negotiated
contracted rate for distribution within this Commonwealth.
(2) The administration or management of prescription drug
benefits provided by a managed care organization.
(3) The administration of pharmacy benefits, including any
of the following:
(i) Operating a mail-service pharmacy.
(ii) Processing claims.
(iii) Managing a retail pharmacy network.
(iv) Paying claims to pharmacies, including retail,
specialty or mail-order pharmacies, for prescription drugs
dispensed to medical assistance recipients receiving services in
the managed care delivery system via a retail or mail-order
pharmacy.
(v) Developing and managing a clinical formulary or
preferred drug list, utilization management or quality assurance
programs.
(vi) Rebate contracting and administration.
(vii) Managing a patient compliance, therapeutic
intervention and generic substitution program.
(viii) Operating a disease management program.
(ix) Setting pharmacy payment pricing and methodologies,
including maximum allowable cost and determining single or
multiple source drugs.
"Pharmacy benefit manager" means a person, business or other
entity that performs pharmacy benefit management. The term
includes a wholly-owned subsidiary of a managed care
organization that performs pharmacy benefits management.
"Pharmacy services administration organization" means a
person, business or other entity that performs any of the
following:
(1) Negotiates or contracts with a managed care organization
or pharmacy benefit manager on behalf of its pharmacy members.
(2) Negotiates payment rates, payments or audit terms on
behalf of its pharmacy members.
(3) Collects or reconciles payments on behalf of its
pharmacy members.
Section 2. The amendment of section 449 of the act shall
apply to any agreement or contract relating to pharmacy services
to medical assistance recipients in the managed care delivery
system entered into or amended on or after the effective date of
this section.
Section 3. This act shall take effect in 60 days.
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