Bill Text: PA HB838 | 2009-2010 | Regular Session | Amended


Bill Title: Providing for access to community pharmacy services.

Spectrum: Moderate Partisan Bill (Democrat 25-4)

Status: (Engrossed - Dead) 2010-06-29 - Re-referred to APPROPRIATIONS [HB838 Detail]

Download: Pennsylvania-2009-HB838-Amended.html

SENATE AMENDED

 

PRIOR PRINTER'S NOS. 945, 1152

PRINTER'S NO.  3868

  

THE GENERAL ASSEMBLY OF PENNSYLVANIA

  

HOUSE BILL

 

No.

838

Session of

2009

  

  

INTRODUCED BY LONGIETTI, EACHUS, CALTAGIRONE, CARROLL, COHEN, DeLUCA, DONATUCCI, FRANKEL, GALLOWAY, GEORGE, GIBBONS, HENNESSEY, JOSEPHS, KORTZ, KOTIK, MANDERINO, MUNDY, MURT, M. O'BRIEN, READSHAW, SIPTROTH, K. SMITH, WALKO, WHEATLEY, YOUNGBLOOD WANSACZ, BRIGGS, VULAKOVICH AND DENLINGER, MARCH 10, 2009

  

  

SENATOR D.WHITE, BANKING AND INSURANCE, IN SENATE, AS AMENDED, JUNE 8, 2010   

  

  

  

AN ACT

  

1

Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An

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act relating to insurance; amending, revising, and

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consolidating the law providing for the incorporation of

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insurance companies, and the regulation, supervision, and

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protection of home and foreign insurance companies, Lloyds

6

associations, reciprocal and inter-insurance exchanges, and

7

fire insurance rating bureaus, and the regulation and

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supervision of insurance carried by such companies,

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associations, and exchanges, including insurance carried by

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the State Workmen's Insurance Fund; providing penalties; and

11

repealing existing laws," further providing for conditions

<--

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subject to which policies are to be issued; and providing for

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health insurance coverage for certain children of insured

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parents providing for access to community pharmacy services.

<--

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The General Assembly of the Commonwealth of Pennsylvania

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hereby enacts as follows:

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Section 1.  Section 617(A)(3) and (9) of the act of May 17,

<--

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1921 (P.L.682, No.284), known as The Insurance Company Law of

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1921, repealed and added May 25, 1951 (P.L.417, No.99) and added

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January 18, 1968 (1967 P.L.969, No.433), are amended to read:

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Section 617.  Conditions Subject to Which Policies Are to Be

 


1

Issued.--(A)  No such policy shall be delivered or issued for

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delivery to any person in this Commonwealth unless:

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* * *

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(3)  it purports to insure only one person, except that a

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policy may insure, originally or by subsequent amendment, upon

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the application of an adult head of a family who shall be deemed

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the policyholder, any two or more eligible members of that

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family, including husband, wife, dependent children or any

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children under a specified age which, except as provided under

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section 617.1, shall not exceed nineteen years and any other

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person dependent upon the policyholder; and

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* * *

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(9)  A policy delivered or issued for delivery after January

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1, 1968, under which coverage of a dependent of a policyholder

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terminates at a specified age shall, with respect to an

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unmarried child covered by the policy prior to the attainment of

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the age of nineteen or except as provided under section 617.1,

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the age of twenty-nine, who is incapable of self-sustaining

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employment by reason of mental retardation or physical handicap

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and who became so incapable prior to attainment of age nineteen

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and who is chiefly dependent upon such policyholder for support

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and maintenance, not so terminate while the policy remains in

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force and the dependent remains in such condition, if the

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policyholder has within thirty-one days of such dependent's

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attainment of the limiting age submitted proof of such

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dependent's incapacity as described herein. The foregoing

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provisions of this paragraph shall not require an insurer to

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insure a dependent who is a mentally retarded or physically

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handicapped child where the policy is underwritten on evidence

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of insurability based on health factors set forth in the

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application or where such dependent does not satisfy the

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conditions of the policy as to any requirement for evidence of

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insurability or other provisions of the policy, satisfaction of

4

which is required for coverage thereunder to take effect. In any

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such case the terms of the policy shall apply with regard to the

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coverage or exclusion from coverage of such dependent.

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* * *

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Section 2.  The act is amended by adding a section to read:

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Section 617.1.  Health Insurance Coverage for Certain

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Children of Insured Parents.--(A)  An insurer that issues,

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delivers, executes or renews health care insurance in this

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Commonwealth, under which coverage of a child would otherwise

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terminate at a specified age, shall, at the option of the

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policyholder's insured employe, provide coverage to a child of

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an insured employe beyond that specified age, up through and

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including the age of twenty-nine, provided that the child meet

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all of the following requirements:

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(1)  Is not married.

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(2)  Has no dependents.

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(3)  Is a resident of this Commonwealth or is enrolled as a

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full-time student at an institution of higher education.

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(4)  Is not covered by another policy of health insurance

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including benefits under Title XVIII of the Social Security Act

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(49 Stat. 620, 42 U.S.C. § 1395 et seq.).

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(B)  An insured may exercise the option provided under

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subsection (A) at any time during the term of the policy by

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notice to the insurer.

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(C)  This section shall not include the following types of

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insurance or any combination thereof:

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(1)  Hospital indemnity.

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(2)  Accident.

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(3)  Specified disease.

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(4)  Disability income.

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(5)  Dental.

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(6)  Vision.

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(7)  Civilian Health and Medical Program of the Uniformed

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Services (CHAMPUS) supplement.

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(8)  Medicare supplement.

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(9)  Long-term care.

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(10)  Other limited benefit plans.

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(11)  Individual health insurance policies.

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(D)  For the purpose of this section:

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"Health care insurance" means a group health, sickness or

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accident policy or subscriber contract or certificate issued by

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an entity subject to any one of the following:

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(1)  This act.

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(2)  The act of December 29, 1972 (P.L.1701, No.364), known

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as the "Health Maintenance Organization Act."

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(3)  The act of May 18, 1976 (P.L.123, No.54), known as the

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"Individual Accident and Sickness Insurance Minimum Standards

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Act."

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(4)  40 Pa.C.S. Ch. 61 (relating to hospital plan

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corporations) or 63 (relating to professional health services

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plan corporations).

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(E)  Employers shall not be required to contribute to any

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increased premium charged by the insurer for the exercise of the

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option provided under subsection (A), but the contributions may

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be agreed to by the employer.

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Section 3.  The amendment or addition of sections 617(A)(3)

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and (9) and 617.1 of the act shall apply to policies offered,

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issued or renewed on or after the effective date of this

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section.

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Section 4.  This act shall take effect in 60 days.

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Section 1.  The act of May 17, 1921 (P.L.682, No.284), known

<--

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as The Insurance Company Law of 1921, is amended by adding a

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section to read:

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Section 635.5.  Access to Community Pharmacy Services.--(a)

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With respect to prescription medications dispensed by a pharmacy

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that agrees to participate in a provider network pursuant to

10

subsection (c), no health insurance policy, government program

11

or pharmacy benefit manager providing coverage or reimbursement

12

for the dispensing of prescription medications may as a

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condition for the provision of benefits or for the payment of

14

reimbursement for medications or pharmacy services:

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(1)  require a covered individual to obtain any prescription

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medication from a mail order pharmacy;

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(2)  impose upon a covered individual utilizing a retail

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community pharmacy any copayment, deductible or other cost-

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sharing requirement or prior authorization requirement not

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imposed upon a covered individual utilizing a mail order

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pharmacy;

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(3)  subject any medication dispensed by a retail community

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pharmacy to a covered individual to a minimum or maximum

24

quantity limit, length of script, restriction on refills or

25

requirement to obtain refills not imposed upon a mail order

26

pharmacy;

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(4)  require a covered individual in whole or in part to pay

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for any medication dispensed by a retail community pharmacy and

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seek reimbursement when the individual is not required to pay

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for and seek reimbursement in the same manner for a prescription

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1

dispensed by a mail order pharmacy;

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(5)  subject a covered individual to any administrative

3

requirement in order to use a retail community pharmacy that is

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not imposed upon the use of a mail order pharmacy, including a

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requirement to elect not to have a prescription dispensed by a

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mail order pharmacy as a condition of utilizing a retail

7

community pharmacy; or

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(6)  impose any other term, condition or requirement

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pertaining to the use of the services of a retail community

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pharmacy that materially and unreasonably interferes with or

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impairs the right of a covered individual to obtain prescription

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medications from a retail community pharmacy of the individual's

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choice.

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(b)  (1)  No health insurance company, agent or contractor of

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an insurance company, government program or pharmacy benefit

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manager shall, in the administration of a health insurance

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policy or a pharmacy provider network, take any action or allow

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any action to occur that results in actions prohibited under

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subsection (a).

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(2)  With respect to prescription medications dispensed by a

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pharmacy eligible to participate in a provider network under

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subsection (c), information regarding the dispensing of

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prescription medications by a pharmacy shall not be used by a

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health insurance company, an agent, affiliate or contractor of

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an insurance company, a government program or by a prescription

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benefit manager to promote, advertise or encourage the use of a

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participating pharmacy, including a mail order pharmacy.

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(c)  (1)  A pharmacy licensed and in good standing with the

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State Board of Pharmacy, and not disqualified from participation

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in the Medicaid or Medicare program for cause, shall have a

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right to participate in a pharmacy provider network, provided

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the pharmacy offers to enter into an agreement accepting the

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standard terms, conditions or requirements relating to

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dispensing fees, payments for product costs and other pharmacy

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services and the quality of dispensing and other pharmacy

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services established by a health insurance company, government

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program or pharmacy benefit manager for all pharmacies in the

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provider network.

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(2)  The standard terms and conditions relating to dispensing

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fees and payment for product costs and other pharmacy services

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established under paragraph (1) shall provide convenient access

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to retail community pharmacies consistent with the standards

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established under section 2121 and taking into consideration the

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standards established by the Center for Medicare and Medicaid

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Services of the United States Department of Health and Human

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Services pursuant to section 1395w-104(b)(1)(C) of the Social

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Security Act (49 Stat. 620, 42 U.S.C. § 1395w-104(b)(1)(C)).

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(3)  The standard terms and conditions relating to dispensing

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fees, ingredient costs and payments for pharmacy services

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provided to retail community pharmacies shall not be less than

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the amounts paid by or for the benefit of a health insurance

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company, government program or pharmacy benefit manager for

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dispensing of the same medications and the provision of

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comparable services to any mail order pharmacy, including

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amounts paid or distributed to a mail order pharmacy by an

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affiliate of the mail order pharmacy or by the pharmacy benefit

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manager.

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(4)  In determining whether the terms and conditions relating

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to dispensing fees, ingredient costs and payments for pharmacy

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services are not less than amounts paid to a mail order pharmacy

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under paragraph (3), consideration shall be given to the extent

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practicable to any incentive payments received for the

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dispensing of prescription medications by a mail order pharmacy

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or an affiliate of a mail order pharmacy, including a pharmacy

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benefit manager, from a pharmaceutical manufacturer or

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distributor other than amounts paid for services provided to a

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pharmaceutical manufacturer or distributor, or amounts used to

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reduce the cost of prescription medication benefits paid by the

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purchaser of a health insurance policy or the services of a

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prescription drug manager, or by a government program.

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(5)  A pharmacy shall not be deemed to be eligible to

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participate in a provider network under this subsection during

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any period of time for which its right to participate in a

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network has been suspended or revoked for serious violations of

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a network pharmacy provider agreement established under this

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subsection that reasonably warrant suspension or revocation.

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(d)  (1)  With respect to a health insurance company or

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pharmacy benefit manager:

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(i)  the department may utilize the enforcement mechanisms,

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remedies and penalties available under section 628 and may

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demand the production of any information necessary to enforce

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this section; and

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(ii)  regardless of whether any enforcement action is taken

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by the department, a covered individual, pharmacy or pharmacist

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aggrieved by a violation of this section may seek relief to

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remedy alleged violations of this section involving at least one

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level of internal review and investigation in the manner

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provided under section 2161(b) and an opportunity to appeal to

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the department in the manner provided under section 2142 unless,

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with respect to a pharmacy or pharmacist, an agreement with the

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insurance company or pharmacy benefit manager establishes an

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alternative dispute resolution process in the manner provided

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under section 2162(f).

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(2)  A covered individual, pharmacy or pharmacist aggrieved

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by a violation of this section may petition the department to

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review complaints regarding violations of this section.

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(e)  It is the intent of the General Assembly that this

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section and the other provisions of Articles VI, VI-A, VI-B, X-A

9

and XII relating to health insurance shall, as applied to

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persons subject to this act to the fullest extent possible, be

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preserved from preemption by Federal law. In the event any

12

portion of this section or Article VI, VI-A, VI-B, X-A or XII

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shall be preempted by Federal law or otherwise declared invalid

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or unenforceable, the remaining provisions of such laws shall

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remain in force and effect.

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(f)  As used in this section:

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(1)  "Covered individual" means an individual receiving

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prescription medication coverage or reimbursement provided by a

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health insurance policy, government program or pharmacy benefit

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manager.

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(2)  "Government program" means any of the following:

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(i)  The Commonwealth's medical assistance program

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established under the act of June 13, 1967 (P.L.31, No.21),

24

known as the "Public Welfare Code."

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(ii)  The adult basic coverage insurance program established

26

under Chapter 13 of the act of June 26, 2001 (P.L.755, No.77),

27

known as the "Tobacco Settlement Act."

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(iii)  The Children's Health Care Program established under

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Article XXIII.

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(iv)  The program of pharmaceutical assistance for the

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elderly established by the act of August 26, 1971 (P.L.351,

2

No.91), known as the "State Lottery Law."

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(v)  An employe benefit plan described in section 1003(b)(1)

4

of the Employee Retirement Income Security Act of 1974 (Public

5

Law 93-46, 29 U.S.C. § 1003(b)(1)), applicable to government

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employes who are residents of this Commonwealth.

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(vi)  Any other program established or operated by the

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Commonwealth that provides or pays for the cost of prescription

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medications and pharmacy services provided to residents of this

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Commonwealth.

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(3)  "Health insurance company" means a fraternal benefit

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society, health maintenance organization, hospital plan

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corporation, insurer, preferred provider organization or

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professional health services plan corporation as defined by

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section 603-B, or other entity subject to this act.

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(4)  "Health insurance policy" means a group or individual

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health or sickness or accident insurance policy, subscriber

18

contract or certificate issued by a health insurance company

19

providing coverage or benefits for prescription medications to

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residents of this Commonwealth.

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(5)  "Mail order pharmacy" means a pharmacy that

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predominantly receives prescriptions by mail, telefax or through

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electronic submissions and predominantly dispenses the

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medications to patients through the use of the United States

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mail or other common or contract carrier delivery service and

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generally provides consultations with patients electronically

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rather than face-to-face.

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(6)  "Pharmacy benefit manager" means a person, partnership,

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association or corporation not holding a certificate of

30

authority under section 630 that establishes, operates,

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1

maintains or administers agreements with pharmacies and health

2

insurance companies, government programs or employe benefit

3

plans described in section 1003(a) of the Employee Retirement

4

Income Security Act of 1974 relating to the dispensing of

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prescription medications and the provision of pharmacy services

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to covered individuals, including agreements relating to the

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amounts to be charged by the pharmacy for services rendered,

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incentives provided to covered individuals to use the services

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of designated pharmacies, or limitations on reimbursement only

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when services are provided by designated pharmacies.

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(7)  "Retail community pharmacy" means a pharmacy that is

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open to the public, serves walk-in customers and makes available

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face-to-face consultations between licensed pharmacists and

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persons to whom medications are dispensed.

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Section 2.  The Insurance Department may adopt regulations to

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administer and enforce section 635.5 of the act.

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Section 3.  Section 635.5 of the act shall apply to health

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insurance policies, government programs and agreements with

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pharmacy benefit managers that are offered, issued, executed or

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renewed or that have provisions related to prescription

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medication benefits that are amended on or after the effective

22

date of section 635.5 of the act.

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Section 4.  This act shall take effect as follows:

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(1)  The addition of section 635.5 of the act shall take

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effect in 120 days.

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(2)  The remainder of this act shall take effect

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immediately.

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