SENATE AMENDED
PRIOR PRINTER'S NO. 1806
PRINTER'S NO. 3605
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
1630
Session of
2021
INTRODUCED BY FRITZ, HEFFLEY, RYAN, BOBACK, RADER, HAMM,
MILLARD, CIRESI, PEIFER, DeLUCA, GROVE, R. BROWN, ZIMMERMAN,
ROAE, FARRY, WELBY AND WEBSTER, JUNE 15, 2021
AS AMENDED ON THIRD CONSIDERATION, IN SENATE, OCTOBER 25, 2022
AN ACT
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,
providing for pharmacy benefits manager audit and
obligations; AND ABROGATING REGULATIONS.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. The act of June 13, 1967 (P.L.31, No.21), known
as the Human Services Code, is amended by adding a section to
read:
Section 449.2. Pharmacy Benefits Manager Audit and
Obligations.--(a) The Department of the Auditor General may
conduct an audit and review of a pharmacy benefits manager that
provides pharmacy benefits management to a medical assistance
managed care organization under contract with the department.
The Department of the Auditor General may review all previous
audits completed by the department and shall have access to all
documents it deems necessary to complete the review and audit.
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(b) Any information disclosed or produced by a pharmacy
benefits manager or a medical assistance managed care
organization for the use of the department or the Department of
the Auditor General 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."
(c) As used in this section, the following words and phrases
shall have the meanings given to them in this subsection:
"Medical assistance managed care organization" means a
Medicaid managed care organization as defined in section 1903(m)
(1)(a) of the Social Security Act (49 Stat. 620, 42 U.S.C. ยง
1396b(m)(1)(A)) that is a party to a Medicaid managed care
contract with the department.
"Pharmacy benefits management" means any of the following:
(1) Procurement of prescription drugs at a negotiated
contracted rate for distribution within this Commonwealth to
covered individuals.
(2) Administration or management of prescription drug
benefits provided by a covered entity for the benefit of covered
individuals.
(3) Administration of pharmacy benefits, including:
(i) Operating a mail-service pharmacy.
(ii) Claims processing.
(iii) Managing a retail pharmacy network management.
(iv) Paying claims to pharmacies for prescription drugs
dispensed to covered individuals by a retail, specialty or mail-
order pharmacy.
(v) Developing and managing a clinical formulary,
utilization management and quality assurance programs.
(vi) Rebate contracting and administration.
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(vii) Managing a patient compliance, therapeutic
intervention and generic substitution program.
(viii) Operating a disease management program.
(ix) Setting pharmacy reimbursement pricing and
methodologies, including maximum allowable cost, and determining
single or multiple source drugs. SHALL HAVE THE SAME MEANING AS
IN SECTION 449.
"Pharmacy benefits manager" means a person, business or other
entity that performs pharmacy benefits management. The term
shall include any affiliated ownership of a medical assistance
managed care organization that performs pharmacy benefits
management.
Section 2. This act shall take effect in 60 days.
SECTION 2. THE FOLLOWING PROVISIONS OF 55 PA. CODE ARE
ABROGATED:
(1) SECTION 1153.14(1) (RELATING TO NONCOVERED
SERVICES).
(2) SECTION 1223.14(2) (RELATING TO NONCOVERED
SERVICES).
(3) SECTION 5230.55(C) (RELATING TO SUPERVISION) TO THE
EXTENT THAT IT REQUIRES A FACE-TO-FACE MEETING.
(4) SECTION 1121.53(C) (RELATING TO LIMITATIONS ON
PAYMENT) TO THE EXTENT THAT PAYMENT FOR PRESCRIPTIONS IS
LIMITED TO A 34-DAY SUPPLY OR 100 UNITS.
(5) TO THE EXTENT PERMITTED UNDER FEDERAL LAW:
(I) SECTION 1249.52(A)(1) (RELATING TO PAYMENT
CONDITIONS FOR VARIOUS SERVICES) AND SECTION 1249.53(A)
(1) (RELATING TO PAYMENT CONDITIONS FOR SKILLED NURSING
CARE) TO THE EXTENT THAT HOME HEALTH SERVICES ARE ONLY
COVERED AND REIMBURSABLE UNDER THE MEDICAL ASSISTANCE
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PROGRAM IF A PHYSICIAN ORDERS THE SERVICES AND
ESTABLISHES THE PLAN OF TREATMENT.
(II) SECTION 1249.54(A)(3) (RELATING TO PAYMENT
CONDITIONS FOR HOME HEALTH AIDE SERVICES) TO THE EXTENT
THAT A HOME HEALTH AIDE SERVICE IS ONLY COVERED AND
REIMBURSABLE UNDER THE MEDICAL ASSISTANCE PROGRAM IF A
PHYSICIAN ESTABLISHES THE WRITTEN PLAN OF TREATMENT AND,
IF SKILLED CARE IS NOT REQUIRED, CERTIFIES THAT THE
PERSONAL CARE SERVICES ARE MEDICALLY NECESSARY.
SECTION 3. THIS ACT SHALL TAKE EFFECT AS FOLLOWS:
(1) THIS SECTION SHALL TAKE EFFECT IMMEDIATELY.
(2) SECTION 2 OF THIS ACT SHALL TAKE EFFECT IMMEDIATELY.
(3) THE REMAINDER OF THIS ACT SHALL TAKE EFFECT IN 60
DAYS.
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