Regular Session 2015-2016 House Bill 2069 P.N. 3689

SENATE AMENDED

PRIOR PRINTER'S NO. 3340

PRINTER'S NO. 3689

THE GENERAL ASSEMBLY OF PENNSYLVANIA

HOUSE BILL

No.

2069

Session of

2015

INTRODUCED BY FARRY, SAMUELSON, HENNESSEY, GROVE, YOUNGBLOOD,

BARRAR, COOK-ARTIS, V. BROWN, DeLUCA, BAKER, GALLOWAY,

WATSON, FREEMAN, DRISCOLL, QUIGLEY, GODSHALL, D. MILLER,

PHILLIPS-HILL, ROZZI, SAINATO, BULLOCK, MILLARD, SCHLOSSBERG,

STAATS, DiGIROLAMO, GIBBONS, D. COSTA, LONGIETTI, HARHAI,

DeLISSIO, RAVENSTAHL, THOMAS, GINGRICH, JOZWIAK, WHITE,

DAVIS, GILLEN, BRIGGS, BARBIN, NELSON AND MATZIE,

MAY 12, 2016

SENATOR BROOKS, AGING AND YOUTH, IN SENATE, AS AMENDED,

JUNE 30, 2016

AN ACT

Amending the act of August 26, 1971 (P.L.351, No.91), entitled

"An act providing for a State Lottery and administration

thereof; authorizing the creation of a State Lottery

Commission; prescribing its powers and duties; disposition of

funds; violations and penalties therefor; exemption of prizes

from State and local taxation and making an appropriation,"

in pharmaceutical assistance for the elderly, further

providing for definitions, for program generally and for

generic drugs, providing for medication synchronization,

further providing for the Pharmaceutical Assistance Contract

for the Elderly Needs Enhancement Tier (PACENET) and for

board and, providing for medication therapy management AND

FURTHER PROVIDING FOR COORDINATION OF BENEFITS.

The General Assembly of the Commonwealth of Pennsylvania

hereby enacts as follows:

Section 1. The definition of "board" in section 502 of the

act of August 26, 1971 (P.L.351, No.91), known as the State

Lottery Law, added November 21, 1996 (P.L.741, No.134), is

amended and the section is amended by adding definitions to

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read:

SECTION 1. THE DEFINITIONS OF "BOARD" AND "INCOME" IN

SECTION 502 OF THE ACT OF AUGUST 26, 1971 (P.L.351, NO.91),

KNOWN AS THE STATE LOTTERY LAW, ADDED NOVEMBER 21, 1996

(P.L.741, NO.134) AND REENACTED AND AMENDED FEBRUARY 7, 2014

(P.L.27, NO.12), ARE AMENDED AND THE SECTION IS AMENDED BY

ADDING DEFINITIONS TO READ:

Section 502. Definitions.

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:

* * *

"Board." The Pharmaceutical Assistance [Review] Advisory

Board.

* * *

"INCOME." ALL INCOME FROM WHATEVER SOURCE DERIVED,

INCLUDING, BUT NOT LIMITED TO, SALARIES, WAGES, BONUSES,

COMMISSIONS, INCOME FROM SELF-EMPLOYMENT, ALIMONY, SUPPORT

MONEY, CASH PUBLIC ASSISTANCE AND RELIEF, THE GROSS AMOUNT OF

ANY PENSIONS OR ANNUITIES, INCLUDING RAILROAD RETIREMENT

BENEFITS, ALL BENEFITS RECEIVED UNDER THE SOCIAL SECURITY ACT

(49 STAT. 620, 42 U.S.C. § 301 ET. SEQ.) NET OF AMOUNTS WITHHELD

FOR MEDICARE PART B PREMIUM PAYMENT, ALL BENEFITS RECEIVED UNDER

STATE UNEMPLOYMENT INSURANCE LAWS AND VETERANS' DISABILITY

PAYMENTS, ALL INTEREST RECEIVED FROM THE FEDERAL GOVERNMENT OR

ANY STATE GOVERNMENT OR ANY INSTRUMENTALITY OR POLITICAL

SUBDIVISION THEREOF, REALIZED CAPITAL GAINS, RENTALS, WORKMEN'S

COMPENSATION AND THE GROSS AMOUNT OF LOSS OF TIME INSURANCE

BENEFITS, LIFE INSURANCE BENEFITS AND PROCEEDS, EXCEPT THE FIRST

$10,000 OF THE TOTAL OF DEATH BENEFITS PAYMENTS, AND GIFTS OF

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CASH OR PROPERTY, OTHER THAN TRANSFERS BY GIFT BETWEEN MEMBERS

OF A HOUSEHOLD, IN EXCESS OF A TOTAL VALUE OF $300, BUT SHALL

NOT INCLUDE SURPLUS FOOD OR OTHER RELIEF IN KIND SUPPLIED BY A

GOVERNMENT AGENCY, THE PRINCIPAL AND ANY INTEREST ACCRUED FROM A

SAVINGS BOND OR PROPERTY TAX REBATE NOR SHALL THE TERM INCLUDE

ANY STATE VETERANS' BENEFIT PAYMENTS .

* * *

"Medication synchronization." The coordination of

prescription drug filling or refilling by a pharmacy or

dispensing physician for a program participant taking two or

more medications for the purpose of improving medication

adherence.

"NADAC per unit." The current National Average Drug

Acquisition Cost per unit.

* * *

"STATE VETERANS' BENEFIT PAYMENTS." SERVICE-CONNECTED

COMPENSATION OR PAYMENTS PROVIDED TO A VETERAN OR AN UNMARRIED

SURVIVING SPOUSE OF A VETERAN BY A STATE AGENCY OR AUTHORIZED

UNDER STATE LAW.

"Wholesale acquisition cost." The cost of a dispensed drug

based upon the price published in a national drug pricing system

in current use by the Department of Aging as the wholesale

acquisition cost of a prescription drug in the most common

package size.

Section 2. Section 509(6) of the act, amended July 7, 2006

(P.L.1061, No.111), is amended and the section is amended by

adding a paragraph to read:

Section 509. Program generally.

The program shall include the following:

* * *

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[(6) The program payment shall be the lower of the

following amounts determined as follows:

(i) 88% of the average wholesale cost of the

prescription drug dispensed:

(A) with the addition of a dispensing fee of the

greater of:

(I) $4 per prescription; or

(II) the amount set by the department by

regulation;

(B) the subtraction of the copayment; and

differential; or

(ii) the pharmacy's usual charge for the drug

dispensed with the subtraction of the copayment and, if

required, the subtraction of the generic differential; or

(iii) if a generic drug, the most current Federal

upper payment limits established in the Medicaid Program

under 42 CFR § 447.332 (relating to upper limits for

multiple source drugs), plus a dispensing fee of $4 or

the amount set by the department by regulation, whichever

is greater minus the copayment. The department shall

update the average wholesale costs and the Federal upper

payment limits at least every 30 days.]

(6.1) If the NADAC per unit is available, the program

payment shall be the lower of the following amounts:

(i) the NADAC per unit:

(A) with the addition of a professional

dispensing fee of thirteen dollars per prescription;

and

(B) the subtraction of the copayment; or

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(ii) the pharmacy's usual and customary charge for

the drug dispensed with the subtraction of the copayment.

(6.2) If the NADAC per unit is unavailable, the program

payment shall be the lower of the following amounts:

(i) the wholesale acquisition cost plus 3.2%:

(A) with the addition of a professional

dispensing fee of thirteen dollars per prescription;

and

(B) the subtraction of the copayment; or

(iii) the pharmacy's usual and customary charge for

the drug dispensed with the subtraction of the copayment.

* * *

Section 3. Section 510(a) and (b) of the act, amended July

7, 2006 (P.L.1061, No.111), are amended to read:

Section 510. Generic drugs.

(a) In general.--Notwithstanding any other statute or

regulation, a brand name product shall be dispensed and not

substituted with an A-rated generic therapeutically equivalent

drug if it is less expensive to the program. If a less expensive

A-rated generic therapeutically equivalent drug is available for

dispensing to a claimant, the provider shall dispense the A-

rated generic therapeutically equivalent drug to the claimant.

The department shall reimburse providers based upon the most

current listing of [Federal upper payment limits established in

the Medicaid Program under 42 CFR § 447.332 (relating to upper

limits for multiple source drugs), plus a dispensing fee as set

forth in section 509(6). The department shall update the average

wholesale costs and the Federal upper payment limits on a

regular basis, at least every 30 days.] the NADAC per unit plus

a professional dispensing fee of $13 per prescription. The

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department shall not reimburse providers for brand name products

except in the following circumstances:

(1) There is no A-rated generic therapeutically

equivalent drug available on the market. This paragraph does

not apply to the lack of availability of an A-rated generic

therapeutically equivalent drug in the providing pharmacy

unless it can be shown to the department that the provider

made reasonable attempts to obtain the A-rated generic

therapeutically equivalent drug or that there was an

unforeseeable demand and depletion of the supply of the A-

rated generic therapeutically equivalent drug. In either

case, the department shall reimburse the provider for [88% of

the average wholesale cost] the NADAC per unit plus a

professional dispensing fee [based on the least expensive A-

rated generic therapeutically equivalent drug for the brand

drug dispensed] of $13 per prescription.

(2) An A-rated generic therapeutically equivalent drug

is deemed by the department, in consultation with a

utilization review committee, to have too narrow a

therapeutic index for safe and effective dispensing in the

community setting. The department shall notify providing

pharmacies of A-rated generic therapeutically equivalent

drugs that are identified pursuant to this paragraph on a

regular basis.

(3) The Department of Health has determined that a drug

shall not be recognized as an A-rated generic therapeutically

equivalent drug for purpose of substitution under section

5(b) of the act of November 24, 1976 (P.L.1163, No.259),

referred to as the Generic Equivalent Drug Law.

(4) At the time of dispensing, the provider has a

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prescription on which the brand name drug dispensed is billed

to the program by the provider at a usual and customary

charge which is equal to or less than the least expensive

usual and customary charge of any A-rated generic

therapeutically equivalent drug reasonably available on the

market to the provider.

(5) The brand name drug is less expensive to the

program.

(b) Generic not accepted.--If a claimant chooses not to

accept the A-rated generic therapeutically equivalent drug

required by subsection (a), the claimant shall be liable for the

copayment and [70% of the average wholesale cost of the brand

name drug] the NADAC per unit.

* * *

Section 4. The act is amended by adding a section to read:

Section 515.1. Medication synchronization.

(a) Prorated daily cost-sharing rate.--The program shall

permit and apply a prorated daily cost-sharing rate to

prescription drugs that are dispensed by a pharmacy for less

than a 30 days' supply if the pharmacist or prescriber

determines the fill or refill to be in the best interest of the

program participant and the program participant requests or

agrees to less than a 30 days' supply for the purpose of

medication synchronization.

(b) Denial of coverage prohibited.--

(1) The program may not deny coverage of a prescription

drug that is made in accordance with a plan among the health

plan, individual beneficiary or group plan, a practitioner

and a pharmacist for the purpose of medication

synchronization.

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(2) The program shall allow a pharmacy to override any

denial codes indicating that a prescription drug is being

refilled too soon for the purposes of medication

synchronization.

(1) The program may not use payment structures

incorporating prorated dispensing fees.

(2) Dispensing fees for partially filled or refilled

prescriptions shall be paid in full for each prescription

drug dispensed, regardless of any prorated copayment for the

program participant or fee paid for alignment services.

Section 5. Section 519(b) AND (D) of the act, amended July

7, 2006 (P.L.1061, No.111), is ARE amended to read:

Section 519. The Pharmaceutical Assistance Contract for the

Elderly Needs Enhancement Tier.

* * *

(b) PACENET eligibility.--A person with an annual income of

not less than $14,500 and not more than [$23,500] $31,000 in the

case of a single person and of not less than $17,700 and not

more than [$31,500] $41,000 in the case of the combined income

of persons married to each other shall be eligible for enhanced

pharmaceutical assistance under this section. A person may, in

reporting income to the department, round the amount of each

source of income and the income total to the nearest whole

dollar, whereby any amount which is less than 50¢ is eliminated.

* * *

(D) COPAYMENT.--

(1) FOR CLAIMANTS UNDER THIS SECTION, THE COPAYMENT

SCHEDULE SHALL BE:

(I) [EIGHT] ELEVEN DOLLARS FOR NONINNOVATOR MULTIPLE

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SOURCE DRUGS AS DEFINED IN SECTION 702; OR

(II) [FIFTEEN] EIGHTEEN DOLLARS FOR SINGLE-SOURCE

DRUGS AND INNOVATOR MULTIPLE-SOURCE DRUGS AS DEFINED IN

SECTION 702.

(2) THE DEPARTMENT SHALL ANNUALLY CALCULATE THE

COPAYMENT SCHEDULES BASED ON THE PRESCRIPTION DRUGS AND

MEDICAL SUPPLIES CONSUMER PRICE INDEX. WHEN THE AGGREGATE

IMPACT OF THE PRESCRIPTION DRUGS AND MEDICAL SUPPLIES

CONSUMER PRICE INDEX EQUALS OR EXCEEDS $1, THE DEPARTMENT

SHALL ADJUST THE COPAYMENT SCHEDULES. EACH COPAYMENT SCHEDULE

SHALL NOT BE INCREASED BY MORE THAN $1 IN A CALENDAR YEAR.

Section 6. Section 520 of the act, amended or added November

21, 1996 (P.L.741, No.134) and November 26, 2003 (P.L.212,

No.37), is amended to read:

Section 520. Board.

(a) Establishment.--The Pharmaceutical Assistance [Review]

Advisory Board is continued to ensure that the program is

providing and continues to provide the assistance intended in a

fiscally responsible manner without excessively hampering the

pharmaceutical industry.

(b) Composition.--The board shall be comprised of the

following [eight] persons:

(1) The Secretary of Aging, who shall serve as its

chairman.

(2) The Secretary of Revenue.

(3) The Secretary of Health.

(4) [Five] Nine public members[, one appointed by the

President pro tempore of the Senate, one appointed by the

Minority Leader of the Senate, one appointed by the Speaker

of the House of Representatives, one appointed by the

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Minority Leader of the House of Representatives and one

appointed by the Governor. Those appointed by the legislative

officers shall include two senior citizens who have not been

a part of the pharmaceutical industry to serve as consumer

advocates, one representative of the pharmaceutical industry

and one practicing Pennsylvania pharmacist. The individual

appointed by the Governor must be a physician. A public

member who misses two consecutive meetings without good cause

acceptable to the chairman shall be replaced by the

appointing authority.] appointed as follows:

(i) Four practicing Pennsylvania pharmacists whose

names are jointly submitted by the Pennsylvania

Pharmacists Association and the Pennsylvania Association

of Chain Drug Stores and then appointed by the following:

(A) One member appointed by the President pro

tempore of the Senate.

(B) one member appointed by the Minority Leader

of the Senate.

House of Representatives.

(D) One member appointed by the Minority Leader

of the House of Representatives.

(ii) Five individuals appointed by the Governor

which include the following:

(A) One representative from the pharmaceutical

industry.

(B) Four senior citizens who have not been a

part of the pharmaceutical industry, two of whom may

be senior advocates.

(5) Should a board vacancy not be filled by the

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appointing authority within 60 days, the power to appoint an

individual to the vacancy shall be given to the Secretary of

Aging.

department pursuant to section 2102 and other appropriate data

sources, the board shall conduct an annual review. The board

shall develop recommendations concerning any changes in the

level of copayment, deductible or in the level of fees paid to

participating pharmacists. The board shall review the

department's therapeutic drug utilization review program on an

ongoing basis. The board may also recommend other changes in the

structure of the program and direct the department to enter into

discussions with the private contractor concerning amendments to

the contract, or the department may enter into such discussion

if it deems necessary. The copayment or deductible schedule

shall only be adjusted on an annual basis.

(c.1) Powers and duties.--The board shall advise on the

following:

(1) The development and implementation of the department

proposals for medication synchronization and medication

therapy management programs and reimbursement methodologies.

(2) Adjustment of the dispensing fee, as needed.

(3) Cost-of-living adjustment increases for medication

synchronization, medication therapy management and the

dispensing fee.

(d) Meetings.--The board shall meet at least two times per

year and not more than four times per year.

Section 7. The act is amended by adding a section to read:

Section 522.1. Medication therapy management.

PACE shall, in consultation with the board, develop a

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proposal for a medication therapy management program by using

retail community pharmacies enrolled in the program. PACE, in

consultation with the board, shall submit the proposal to the

General Assembly no later than one year after the effective date

of this section.

SECTION 8. SECTION 534(B)(4) OF THE ACT, ADDED JULY 7, 2006

(P.L.1061, NO.111), IS REPEALED:

SECTION 534. COORDINATION OF BENEFITS.

* * *

(B) SPECIFIC COORDINATION PROVISIONS.--THE FOLLOWING

PROVISIONS SHALL APPLY TO CLAIMANTS WHO ARE ALSO PART D

ENROLLEES:

* * *

[(4) PART D ENROLLEES ENROLLED IN PACENET SHALL PAY THE

PART D PREMIUMS CHARGED BY THEIR PDP OR, WITH RESPECT TO THE

PRESCRIPTION DRUG PLAN, MEDICARE ADVANTAGE PRESCRIPTION DRUG

PLAN AND THE PROGRAM SHALL PAY ANY COPAYMENTS IN EXCESS OF

THOSE SET FORTH IN SECTION 519.]

* * *

Section 8 9. This act shall take effect immediately.

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