Bill Text: IA SF333 | 2023-2024 | 90th General Assembly | Introduced

---

Bill Title: A bill for an act relating to pharmacy benefits managers, pharmacies, and prescription drug benefits, and including applicability provisions.

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced - Dead) 2023-02-27 - Subcommittee recommends amendment and passage. []. [SF333 Detail]

Download: Iowa-2023-SF333-Introduced.html

---

Senate File 333 - Introduced
SENATE FILE 333
BY KLIMESH
A BILL FOR
An Act relating to pharmacy benefits managers, pharmacies, and
prescription drug benefits, and including applicability
provisions.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
TLSB 1508XS (2) 90
ko/rn

S.F. 333
Section 1. Section 510B.8, Code 2023, is amended by adding
the following new subsections:
NEW SUBSECTION . 3. Any amount paid by a covered person for
a prescription drug purchased pursuant to this section shall
be applied to any deductible imposed by the covered person’s
health benefit plan in accordance with the health benefit plan
coverage documents.
NEW SUBSECTION . 4. A covered person shall not be prohibited
from filling a prescription drug order at any pharmacy located
in the state provided that the pharmacy accepts the same terms
and conditions as the pharmacies participating in the covered
person’s health benefit plan’s network.
NEW SUBSECTION . 5. Excluding incentives in value-based
programs established by a health carrier or a pharmacy benefits
manager to promote the use of higher quality pharmacies,
a pharmacy benefits manager shall not impose different
cost-sharing or additional fees on a covered person based on
the pharmacy at which the covered person fills the covered
person’s prescription drug order.
NEW SUBSECTION . 6. A pharmacy benefits manager shall
not require a covered person, as a condition of payment
or reimbursement, to purchase pharmacy services, including
prescription drugs, exclusively through a mail-order pharmacy.
Sec. 2. Section 510B.8A, subsection 2, paragraph a, Code
2023, is amended to read as follows:
a. Provide each pharmacy in a pharmacy network reasonable
access to the maximum allowable cost list to which the pharmacy
is subject via a secure accessible internet site .
Sec. 3. NEW SECTION . 510B.8D Appeals and disputes.
1. A pharmacy benefits manager shall provide a reasonable
process to allow a pharmacy to appeal a maximum allowable cost
or reimbursement rate for a specific prescription drug for any
of the following reasons:
a. The pharmacy benefits manager violated section 510B.8A.
b. The maximum allowable cost or the reimbursement rate is
-1-
LSB 1508XS (2) 90
ko/rn 1/ 4

S.F. 333
below the pharmacy acquisition cost.
2. The appeal process must include all of the following:
a. A dedicated telephone number at which a pharmacy may
contact the pharmacy benefits manager and speak directly with
an individual involved in the appeal process.
b. A dedicated electronic mail address or internet site for
the purpose of submitting an appeal directly to the pharmacy
benefits manager.
c. A period of at least thirty business days after the date
of a pharmacy’s initial submission of a clean claim during
which the pharmacy may initiate an appeal.
3. A pharmacy benefits manager shall respond to an appeal
within seven business days after the date on which the pharmacy
benefits manager receives the appeal.
a. If the pharmacy benefits manager grants a pharmacy’s
appeal, the pharmacy benefits manager shall do all of the
following:
(1) Adjust the maximum allowable cost or the reimbursement
rate of the prescription drug that is the subject of the appeal
and provide the national drug code number that the adjustment
is based on to the appealing pharmacy.
(2) Permit the appealing pharmacy to reverse and resubmit
the claim that is the subject of the appeal.
(3) Make the adjustment pursuant to subparagraph (1)
applicable to all of the following:
(a) Each pharmacy that is under common ownership with the
pharmacy that submitted the appeal.
(b) Each pharmacy in the state that demonstrates the
inability to purchase the prescription drug for less than the
established maximum allowable cost or reimbursement rate.
b. If the pharmacy benefits manager denies a pharmacy’s
appeal, the pharmacy benefits manager shall do all of the
following:
(1) Provide the appealing pharmacy the national drug
code number and the name of a wholesale distributor licensed
-2-
LSB 1508XS (2) 90
ko/rn 2/ 4

S.F. 333
pursuant to section 155A.17 from which the pharmacy can obtain
the prescription drug at or below the maximum allowable cost
or reimbursement rate.
(2) If the prescription drug identified by the national drug
code number provided by the pharmacy benefits manager pursuant
to subparagraph (1) is not available below the pharmacy
acquisition cost from the wholesale distributor from whom the
pharmacy purchases the majority of its prescription drugs for
resale, the pharmacy benefits manager shall adjust the maximum
allowable cost or the reimbursement rate above the appealing
pharmacy’s pharmacy acquisition cost, and permit the pharmacy
to reverse and resubmit each claim affected by the pharmacy’s
inability to procure the prescription drug at a cost that is
equal to or less than the previously appealed maximum allowable
cost or the reimbursement rate.
Sec. 4. APPLICABILITY. This Act applies to pharmacy
benefits managers that manage a health carrier’s prescription
drug benefit in the state on or after the effective date of
this Act.
EXPLANATION
The inclusion of this explanation does not constitute agreement with
the explanation’s substance by the members of the general assembly.
This bill relates to pharmacy benefits managers (PBM),
pharmacies, and prescription drug benefits.
The bill requires that any amount paid by a covered person
for a drug in the circumstances detailed in the bill must
be applied to any deductible imposed by the covered person’s
health benefit plan in accordance with the plan’s coverage
documents. Under the bill, a covered person cannot be
prohibited from filling a drug order at any pharmacy located in
the state if the pharmacy accepts the same terms and conditions
as the covered person’s benefit plan. A PBM cannot impose
different cost-sharing or additional fees on a covered person
based on the pharmacy at which a covered person fills their
prescription. A PBM cannot require a covered person, as a
-3-
LSB 1508XS (2) 90
ko/rn 3/ 4

S.F. 333
condition of payment or reimbursement, to purchase pharmacy
services, including drugs, exclusively through a mail-order
pharmacy.
The bill requires a PBM to provide each pharmacy in a network
access to the maximum allowable cost list (MACL) to which the
pharmacy is subject via a secure accessible internet site.
The bill requires a PBM to provide a process for pharmacies
to appeal a maximum allowable cost, or a reimbursement made
under a MACL. The requirements for the appeal process are
detailed in the bill.
The bill applies to PBMs that manage a health carrier’s
prescription drug benefit in the state on or after the
effective date of the bill.
-4-
LSB 1508XS (2) 90
ko/rn 4/ 4