PRINTER'S NO. 4183
No. 2947 Session of 1990
INTRODUCED BY TRELLO, DeLUCA, COY, CAPPABIANCA, MELIO, KOSINSKI,
MICOZZIE, LaGROTTA, BELARDI, HARPER, OLASZ, RYBAK, VAN HORNE,
NAHILL, CORRIGAN, CARLSON, PESCI, JOHNSON, MAIALE, GIGLIOTTI,
MIHALICH, LAUGHLIN, E. Z. TAYLOR, MORRIS, JOSEPHS, THOMAS,
CIVERA, ADOLPH AND J. TAYLOR, OCTOBER 2, 1990
REFERRED TO COMMITTEE ON YOUTH AND AGING, OCTOBER 2, 1990
AN ACT
1 Amending the act of November 4, 1983 (P.L.217, No.63), entitled
2 "An act establishing a program of limited pharmaceutical
3 assistance for the elderly; granting powers to and imposing
4 duties on the Department of Aging; establishing a payment
5 system; making provisions for funding; providing for reports;
6 and fixing penalties for violations of the pharmaceutical
7 assistance program," providing for a fixed copayment for a
8 prescription filled with a generic drug.
9 The General Assembly of the Commonwealth of Pennsylvania
10 hereby enacts as follows:
11 Section 1. Section 4(e) of the act of November 4, 1983
12 (P.L.217, No.63), known as the Pharmaceutical Assistance
13 Contract for the Elderly Act, amended June 30, 1987 (P.L.169,
14 No.17), is amended to read:
15 Section 4. Responsibilities of Department of Aging.
16 * * *
17 (e) Program criteria.--The program shall include the
18 following criteria:
19 (1) Participating pharmacies are to be paid within 21
1 days of the contracting firm receiving the appropriate
2 substantiation of the transaction. Pharmacies shall be
3 entitled to interest for payment not made within the 21-day
4 period at a rate approved by the Pharmaceutical Assistance
5 Review Board.
6 (2) Collection of the copayment by pharmacies shall be
7 mandatory.
8 (3) Senior citizens participating in the program are not
9 required to maintain records of each transaction.
10 (4) A system of rebates or reimbursements to eligible
11 claimants for pharmaceutical expenses shall be prohibited.
12 (5) The system established shall include a participant
13 copayment schedule of $4 for each prescription for the first
14 year of the contract. The copayment shall increase or
15 decrease on the annual basis by the average percent change of
16 ingredient costs for all prescription drugs plus a
17 differential to raise the copayment to the next highest 25¢
18 increment. In addition, the department may approve a request
19 for increase or decrease in the level of copayment based upon
20 the financial experience and projections of the program and
21 after consultation with the Pharmaceutical Assistance Review
22 Board. The department is prohibited from approving
23 adjustments to the copayment on more than a semiannual basis.
24 (5.1) Notwithstanding paragraph (5) the copayment for a
25 prescription filled with a generically equivalent drug shall
26 be $2. This amount shall not be subject to the adjustment
27 procedures of this act.
28 (6) The program shall consist of payments to pharmacies
29 on behalf of eligible claimants for the average wholesale
30 cost of drugs, insulin, insulin syringes and insulin needles
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1 which exceed the copayment plus a dispensing fee of at least
2 $2.50 or the dispensing fee required by the Department of
3 Welfare under its Medical Assistance Program under the act of
4 June 13, 1967 (P.L.31, No.21), known as the Public Welfare
5 Code, whichever is greater.
6 (6.1) The average wholesale cost shall be based on a
7 list of package sizes to be established by the department.
8 The list shall reflect the average wholesale cost of drugs
9 based on the package size listed in the February 1984 "Yellow
10 Book" distributed by the Health Care Financing Administration
11 for the drugs contained on that list. The Department of Aging
12 shall have the authority to change the package size of drugs
13 on that list and to add drugs and package sizes to that list,
14 with the review and approval of the Pharmaceutical Assistance
15 Review Board. Changes to the list shall take effect upon
16 publication in the Pennsylvania Bulletin. The department
17 shall have the authority to reimburse based upon the package
18 sizes established in this paragraph.
19 (6.2) In no case shall the Commonwealth be charged more
20 than the price of the drug at the particular pharmacy on the
21 date of the sale.
22 (6.3) For purposes of this act, the eligible claimant
23 shall be liable to pay a fixed differential whenever a more
24 expensive brand name drug is requested by the claimant when
25 the physician permitted substitution of a less expensive
26 generically equivalent drug approved under the provisions of
27 the act of November 24, 1976 (P.L.1163, No.259), referred to
28 as the Generic Equivalent Drug Law.
29 (6.4) The differential will be charged regardless of the
30 availability of a less expensive generic equivalent in the
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1 providing pharmacy. In no case will the claimant bear the
2 cost of the differential when the generic equivalent is not
3 available.
4 (6.5) The department shall establish a pharmacist
5 consultation reimbursement program for a period of not less
6 than six months, following which the department may continue
7 or discontinue the program. This program shall provide an
8 additional $1 supplemental dispensing fee whenever a
9 pharmacy's documented intervention resulted in a physician
10 changing a prescription for a more expensive brand name
11 product to a prescription allowing substitution of a less
12 expensive generically equivalent drug. This supplemental
13 dispensing fee shall provide the only exception to paragraph
14 (6.3).
15 (7) Prescription benefits for any single prescription
16 shall be limited to a 30-day supply of the prescription drug
17 or 100 units, whichever is less, except that, in the case of
18 diagnosis for acute conditions, the limitation shall be a 15-
19 day supply.
20 (8) The department may establish a restricted formulary
21 of the drugs which will not be reimbursed by the program.
22 This formulary shall include only experimental drugs and
23 drugs on Drug Efficacy Study Implementation List prepared by
24 the Health Care Finance Administration. A medical exception
25 may be permitted by the department for reimbursement of a
26 drug on the Drug Efficacy Study Implementation List upon
27 declaration of its necessity on the prescription by the
28 treating physician; except that, for DESI drugs for which the
29 FDA has issued a Notice for Opportunity Hearing (NOOH) for
30 the purpose of withdrawing the New Drug Application approved
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1 for that drug, reimbursement coverage shall be discontinued
2 under the provisions of this act.
3 (9) The department may not enter into a contract with a
4 private contractor for an exclusive mail order system for the
5 delivery of prescription drugs under this program. Only mail
6 order pharmacy services provided by pharmacies which are
7 licensed by the Commonwealth and which have their principal
8 place of business within this Commonwealth may participate as
9 providers under the program. Within a period of six months
10 following the effective date of this amendatory act, the
11 department shall develop and promulgate specific regulations
12 governing the practice of mail order pharmacy and other
13 enrolled providers to include the following minimum standards
14 of practice to ensure the health, safety and welfare of
15 program participants:
16 (i) The appropriate method or methods by which such
17 pharmacies shall verify the identity of the program
18 recipient and the authenticity of prescriptions received.
19 (ii) The appropriate method or methods by which such
20 pharmacies shall mail or deliver prescription drugs to
21 program recipients ensuring, to the maximum extent
22 possible, that the intended program recipient is the
23 actual ultimate recipient of any prescription dispensed
24 by such pharmacies.
25 (iii) The appropriate method or methods by which
26 such pharmacies shall communicate with program
27 participants in emergency situations.
28 (10) The program must be in place and operational within
29 90 days of the effective date of the contract.
30 (11) For-profit third party insurers and not-for-profit
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1 prescription plans shall reimburse the department for any
2 payments made to a providing pharmacy on behalf of a claimant
3 covered by such a third party.
4 (12) Any health care professional rendering service as a
5 member of a utilization review committee for this program
6 shall not be liable for any civil damages as a result of any
7 acts or omissions in rendering the service as a member of any
8 such committee except any acts or omissions intentionally
9 designed to harm or any grossly negligent acts or omissions
10 which result in harm to the person receiving such service.
11 * * *
12 Section 2. This act shall take effect in 60 days.
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