PRINTER'S NO. 167
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
195
Session of
2019
INTRODUCED BY NELSON, PICKETT, STURLA, LONGIETTI, DIAMOND,
McNEILL, OTTEN, DELOZIER, RYAN, WARREN, BARRAR, READSHAW,
CALTAGIRONE, JAMES, HILL-EVANS, RADER, GROVE, DeLUCA, KORTZ,
DeLISSIO, T. DAVIS, KAUFFMAN, NEILSON, FARRY, ROTHMAN,
HENNESSEY, BIZZARRO, SIMMONS, B. MILLER, BOYLE, DRISCOLL,
STRUZZI, KLUNK, RIGBY, BERNSTINE, MARSHALL, SAYLOR, FRITZ,
NESBIT, REESE, BOBACK AND THOMAS, JANUARY 28, 2019
REFERRED TO COMMITTEE ON INSURANCE, JANUARY 28, 2019
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 policy ." An individual or group 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 health insurance policy
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.
(2) The act of December 29, 1972 (P.L.1701, No.364),
known as the Health Maintenance Organization Act.
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(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 health insurance enrollee taking two
or more maintenance medications for the purpose of improving
medication adherence.
"Pharmacy." As defined in section 2 of the act of September
27, 1961 (P.L.1700, No.699), known as the Pharmacy Act.
§ 3902. Prorated daily cost-sharing rate.
A health insurance policy shall permit and apply a prorated
daily cost-sharing rate to maintenance medications that are
dispensed by a pharmacy as a partial supply if the pharmacist or
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 policy .
§ 3903. Denial of coverage.
(a) Partial supply.-- A health insurance policy providing
prescription drug coverage may not deny coverage for the
dispensing of a maintenance medication that is dispensed by a
network pharmacy on the basis that the dispensing is for a
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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 health insurance policy shall accept
early refill and partial supply requests for maintenance
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 health insurance
policy .
(c) Compliance.--Nothing in this chapter may prohibit a
health insurance policy from using other methods to comply with
this chapter.
§ 3904. Certain payment structures prohibited.
(a) Prorated dispensing fees.-- A health insurance plan
providing prescription drug coverage may not use payment
structures incorporating prorated dispensing fees.
(b) Full payment.--Dispensing fees for a partial supply 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.
(a) Prescription drugs.-- This chapter does not apply to
prescription drugs that are:
(1) 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
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Cosmetic Act.
(b) Health insurance policies.--This chapter shall apply to
health insurance policies as follows:
(1) For a health insurance policy for which either rates
or forms are required to be filed with the Federal Government
or the Insurance Department, this chapter shall apply to a
health insurance policy for which a form or rate is first
permitted to be used on or after the effective date of this
section.
(2) For a health insurance policy for which neither
rates nor forms are required to be filed with the Federal
Government or the Insurance Department, this chapter shall
apply to a health insurance policy issued or renewed on or
after the effective date of this section.
Section 2. This act shall take effect in 365 days.
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