H1993B3317A05205 SFR:MAC 06/26/24 #90 A05205
AMENDMENTS TO HOUSE BILL NO. 1993
Sponsor: REPRESENTATIVE GAYDOS
Printer's No. 3317
Amend Bill, page 1, line 13, by inserting after "REQUIRED"
and for sharing of cost, benefit and coverage data required
Amend Bill, page 10, line 3, by striking out "A SECTION" and
inserting
sections
Amend Bill, page 11, by inserting between lines 9 and 10
Section 703.2. Sharing of cost, benefit and coverage data
required.
(a) General rule.--A health insurer or PBM shall, upon
request of a covered individual, the covered individual's health
care practitioner or a third party on behalf of the covered
individual or health care practitioner, furnish the cost,
benefit and coverage data specified in subsection (d) to the
covered individual, the health care practitioner or the third
party and shall ensure that such data is:
(1) Current no later than one business day after any
change is made.
(2) Provided in real time.
(3) In the same format that the request is made by the
covered individual, the health care practitioner or the third
party.
(b) Format of request.--The request must be submitted with
established industry content and transport standards published
by:
(1) a standards developing organization accredited by
the American National Standards Institute, including the
National Council for Prescription Drug Programs, ASC X12,
Health Level 7; or
(2) a relevant Federal or State governing body,
including the Centers for Medicare and Medicaid Services or
the Office of the National Coordinator for Health Information
Technology.
(c) Electronic formats unacceptable.--A facsimile,
proprietary payor or patient portal or other electronic form
shall not be considered an acceptable electronic format under
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this section.
(d) Required data.--Upon request, the following data shall
be provided for a drug covered under the covered individual's
health policy:
(1) The covered individual's eligibility information for
the drug.
(2) A list of clinically-appropriate alternatives to the
drug covered under the covered individual's health plan.
(3) Cost-sharing information for the drug and
alternatives, including a description of a variance in cost-
sharing based on pharmacy, whether retail or mail order, or
health care provider dispensing or administering the drug or
alternative.
(4) The applicable utilization management requirements
for the drug or alternatives, including prior authorization,
step therapy, quantity limits and site-of-service
restrictions.
(e) Duty to provide information.--A health insurer or PBM
shall furnish the data specified in subsection (d), whether the
request is made using the drug's unique billing code, such as a
National Drug Code or Healthcare Common Procedure Coding System
code, or descriptive term, such as the brand or generic name of
the drug.
(f) Prohibited conduct.--
(1) A health insurer or PBM may not deny or delay a
request as a method of blocking the data specified in
subsection (d) from being shared based on how the drug was
requested.
(2) A health insurer or PBM furnishing the data
specified in subsection (d) may not:
(i) Restrict, prohibit or otherwise hinder a health
care professional or health care provider from
communicating or sharing the data specified in subsection
(d) or additional information on a lower-cost or
clinically appropriate alternative, whether or not
covered under the covered individual's plan or additional
payment or cost-sharing information that may reduce the
patient's out-of-pocket costs, such as cash price or
patient assistance and support programs whether sponsored
by a manufacturer, foundation or other entity.
(ii) Except as may be required by law, interfere
with, prevent or materially discourage access to,
exchange or use of the data specified in subsection (d),
including charging fees, not responding to a request at
the time made where a response is reasonably possible,
implementing technology in nonstandard ways or
instituting covered individual consent requirements,
processes, policies, procedures or renewals that are
likely to substantially increase the complexity or burden
of accessing, exchanging or using the data.
(iii) Penalize a health care practitioner for
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disclosing the data specified in subsection (d) to a
covered individual or prescribing, administering or
ordering a clinically appropriate or lower-cost
alternative.
(g) Personal representatives.--
(1) For the purposes of this section, a health insurer
or PBM shall treat a personal representative as the covered
individual.
(2) If, under applicable law, a person has authority to
act on behalf of a covered individual in making decisions
relating to health care, a health insurer or PBM or an
affiliate or entity acting on its behalf, shall treat the
person as a personal representative under this section.
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