Bill Text: GA SB3 | 2009-2010 | Regular Session | Introduced

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Bill Title: Prescription Drugs; provide for prior authorization requirements; definitions; penalties; discounts; PeachCare for Kids Program

Spectrum: Moderate Partisan Bill (Republican 5-1)

Status: (Introduced - Dead) 2009-01-14 - Senate Read and Referred [SB3 Detail]

Download: Georgia-2009-SB3-Introduced.html

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09 LC 37 0798

Senate Bill 3

By: Senators Murphy of the 27th, Hawkins of the 49th, Williams of the 19th, Thomas of the 54th, Harbison of the 15th and others

A BILL TO BE ENTITLED
AN ACT

To amend Article 1 of Chapter 24 of Title 33 of the Official Code of Georgia Annotated, relating to general provisions relative to insurance, so as to provide for legislative intent; to provide for prior authorization requirements for a prescription drug; to provide for definitions; to provide for penalties; to provide for discounts; to provide for the Commissioner of Insurance to establish oversight of the operation of pharmacy benefits managers; to amend Title 49 of the Official Code of Georgia Annotated, relating to social services, so as to require the Department of Community Health to modify the state plan to require that in certain circumstances only generic drugs shall be distributed to recipients of drugs under the state plan; to require prescription drug programs under the PeachCare for Kids Program to distribute generic drugs when appropriate; to provide for related matters; to repeal conflicting laws; and for other purposes.

BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:

SECTION 1.

(a) The General Assembly finds and declares that it is a vital government concern that the citizens of the State of Georgia have access to the appropriate prescription drugs in the most effective and timely fashion, as the health care market becomes increasingly dominated by health care plans using cost savings techniques that include drug prior authorization programs that decide which drugs patients may or may not be prescribed despite their health care professional's prescription. The General Assembly also finds and declares that it is a vital government function to protect patients from drug prior authorization practices which have the effect of denying or limiting appropriate drugs.

(b) To achieve these ends, the General Assembly declares it necessary to provide for restrictions of cost shifting to physicians and patients the costs associated to these parties in time and money to comply with these programs, as well as protecting the lives of the patients adversely affected by requirements to fail on a series of drugs or change from a drug that has proven effective simply to comply with their plan's or provider's preferred drug list.

SECTION 2.

Article 1 of Chapter 24 of Title 33 of the Official Code of Georgia Annotated, relating to general provisions relative to insurance, is amended by adding a new Code section to read as follows:

"33-24-59.13.

(a) As used in this Code section, the term:

(1) 'Covered entity' means a nonprofit hospital or medical service organization, an insurer, a health coverage plan or health maintenance organization, a health program administered by the department or this state in the capacity of provider of health coverage, or an employer, labor union, or other group of persons organized in this state that provides health coverage to covered individuals who are employed or reside in this state.

(2) 'Health benefit plan or policy' means any individual or group plan, policy, or contract for health care services issued, delivered, issued for delivery, or renewed in this state, including, but not limited to, a health care corporation, health maintenance organization, preferred provider organization, accident and sickness insurer, fraternal benefit society, hospital service corporation, medical service corporation, workers' compensation insurance carrier in accordance with Chapter 9 of Title 34, other insurer or similar entity, and the state health benefit plan under Article 1 of Chapter 18 of Title 45 but shall not mean the medical assistance program administered under Article 7 of Chapter 4 of Title 49 and the PeachCare for Kids Program under Article 13 of Chapter 5 of Title 49.

(3) 'Insurer' means a health care corporation, health maintenance organization, preferred provider organization, accident and sickness insurer, fraternal benefit society, hospital service corporation, medical service corporation, workers' compensation insurance carrier in accordance with Chapter 9 of Title 34, managed care plan other than a dental plan, or any similar entity authorized to issue contracts under Title 33 and shall also include the state for purposes of the state health benefit plan under Article 1 of Chapter 18 of Title 45 but shall not mean the medical assistance program administered under Article 7 of Chapter 4 of Title 49 and the PeachCare for Kids Program under Article 13 of Chapter 5 of Title 49.

(4) 'Pharmacy benefits manager' means any person, corporation, or other entity that administers the prescription drug, prescription device, or both prescription drug and device portion of a health benefit plan on behalf of an insurer. The term includes a person or entity acting for a pharmacy benefits manager in a contractual or employment relationship in the performance of pharmacy benefits management for a covered entity.

(5) 'Prescription drug' has the meaning provided by Code Section 26-4-5.

(b) Insurers shall establish procedures to ensure there is a response to a request for prior authorization for a prescription drug by telephone or other telecommunication device within 24 hours after receipt of such a request. In the event the authorization is not received within 24 hours as required in this subsection, or in an emergency, a 72 hour supply of the drug prescribed shall be provided.

(c) Insurers shall utilize a step-therapy prior authorization approval process for medications excluded from such insurers' preferred drug lists. The process may require that one medication from the same class and listed on the preferred drug list be used within the previous 12 months prior to a patient moving to an alternative medication not listed on such preferred drug list. Authorization for the use of a nonpreferred drug shall be for no less than a 12 month period. The trial period between the specified steps may vary according to the medical indication.

(d) A physician shall be reimbursed by the insurer or the pharmacy benefits manager when prior approvals for that insurer or pharmacy benefits manager exceed 10 in a 30 day period at the rate of $10.00 per prior approval.

(e) In the event a patient is required to incur additional visits to the pharmacy as a result of the prior approval process, the insurer or pharmacy benefits management company shall provide the patient a 12 percent decrease in the charge for the prescription drug.

(f) A patient who has received a nonpreferred drug shall be permitted to continue using the drug if the drug has been removed from the preferred drug list or if the patient has changed to a plan or provider that does not list the drug on such plan's or provider's preferred drug list.

(g) In the event the health benefit plan or policy or pharmacy benefits manager requires a different drug than that prescribed by the patient's physician, the health benefit plan or policy or pharmacy benefits manager managing the prescription benefits of the patient is liable for any adverse consequences of such drug."

SECTION 3.

Said article is further amended by adding a new Code section to read as follows:

"33-24-59.14.

There shall be established by the Commissioner within the department an oversight committee. The purpose of this committee shall be to advise the legislature on the conduct of pharmacy benefits managers operating in this state. This conduct shall include, but not be limited to, business practices involving drug prior authorization programs, rebate programs, the evolving certification process, and any regulations of the industry by other states. The Commissioner may not enlarge upon or extend the provisions of this Code section through any act, rule, or regulation."

SECTION 4.

Title 49 of the Official Code of Georgia Annotated, relating to social services, is amended in Article 7 of Chapter 4, relating to medical assistance generally, by adding a new subsection to Code Section 49-4-142, relating to adoption, administration, and modification of the state plan, to read as follows:

"(d) The department shall implement a modification of the state plan for medical assistance or any affected rules and regulations of the department, which modification shall require that any program administering the distribution of prescription drugs to a recipient of medical assistance shall distribute generic drugs when available or appropriate in accordance with department guidelines. The modification to the plan or to any affected rules and regulations shall be effective unless and until federal authorities rule that such modification is out of compliance with federal regulations. Nothing in this subsection shall be interpreted to preempt the authority of a practitioner of the healing arts to require a brand drug pursuant to Code Section 26-4-81."

SECTION 5.

Said title is further amended in Article 13 of Chapter 5, relating to PeachCare for Kids, by adding a new Code section to read as follows:

"49-5-274.

Any prescription drug program administered under PeachCare distributing prescription drugs to recipients of the program shall require the distribution of generic drugs when available or appropriate in accordance with department guidelines. The department is authorized to modify the plan required pursuant to subsection (i) of Code Section 49-5-273 as is necessary to implement this Code section. The modification of such plan and the requirements of this Code section shall be effective unless and until federal authorities rule that such modification is out of compliance with federal regulations. Nothing in this Code section shall be interpreted to preempt the authority of a practitioner of the healing arts to require a brand drug pursuant to Code Section 26-4-81."

SECTION 6.

All laws and parts of laws in conflict with this Act are repealed.