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

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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

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SENATE AMENDED
PRIOR PRINTER'S NOS. 945, 1152 PRINTER'S NO. 3868
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No. 838 Session of2009
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
Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An
act relating to insurance; amending, revising, and
consolidating the law providing for the incorporation of
insurance companies, and the regulation, supervision, and
protection of home and foreign insurance companies, Lloyds
associations, reciprocal and inter-insurance exchanges, and
fire insurance rating bureaus, and the regulation and
supervision of insurance carried by such companies,
associations, and exchanges, including insurance carried by
the State Workmen's Insurance Fund; providing penalties; and
repealing existing laws," further providing for conditions <--
subject to which policies are to be issued; and providing for
health insurance coverage for certain children of insured
parents providing for access to community pharmacy services. <--
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Section 617(A)(3) and (9) of the act of May 17, <--
1921 (P.L.682, No.284), known as The Insurance Company Law of
1921, repealed and added May 25, 1951 (P.L.417, No.99) and added
January 18, 1968 (1967 P.L.969, No.433), are amended to read:
Section 617. Conditions Subject to Which Policies Are to Be
Issued.--(A) No such policy shall be delivered or issued for
delivery to any person in this Commonwealth unless:
* * *
(3) it purports to insure only one person, except that a
policy may insure, originally or by subsequent amendment, upon
the application of an adult head of a family who shall be deemed
the policyholder, any two or more eligible members of that
family, including husband, wife, dependent children or any
children under a specified age which, except as provided under
section 617.1, shall not exceed nineteen years and any other
person dependent upon the policyholder; and
* * *
(9) A policy delivered or issued for delivery after January
1, 1968, under which coverage of a dependent of a policyholder
terminates at a specified age shall, with respect to an
unmarried child covered by the policy prior to the attainment of
the age of nineteen or except as provided under section 617.1,
the age of twenty-nine, who is incapable of self-sustaining
employment by reason of mental retardation or physical handicap
and who became so incapable prior to attainment of age nineteen
and who is chiefly dependent upon such policyholder for support
and maintenance, not so terminate while the policy remains in
force and the dependent remains in such condition, if the
policyholder has within thirty-one days of such dependent's
attainment of the limiting age submitted proof of such
dependent's incapacity as described herein. The foregoing
provisions of this paragraph shall not require an insurer to
insure a dependent who is a mentally retarded or physically
handicapped child where the policy is underwritten on evidence
of insurability based on health factors set forth in the
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application or where such dependent does not satisfy the
conditions of the policy as to any requirement for evidence of
insurability or other provisions of the policy, satisfaction of
which is required for coverage thereunder to take effect. In any
such case the terms of the policy shall apply with regard to the
coverage or exclusion from coverage of such dependent.
* * *
Section 2. The act is amended by adding a section to read:
Section 617.1. Health Insurance Coverage for Certain
Children of Insured Parents.--(A) An insurer that issues,
delivers, executes or renews health care insurance in this
Commonwealth, under which coverage of a child would otherwise
terminate at a specified age, shall, at the option of the
policyholder's insured employe, provide coverage to a child of
an insured employe beyond that specified age, up through and
including the age of twenty-nine, provided that the child meet
all of the following requirements:
(1) Is not married.
(2) Has no dependents.
(3) Is a resident of this Commonwealth or is enrolled as a
full-time student at an institution of higher education.
(4) Is not covered by another policy of health insurance
including benefits under Title XVIII of the Social Security Act
(49 Stat. 620, 42 U.S.C. § 1395 et seq.).
(B) An insured may exercise the option provided under
subsection (A) at any time during the term of the policy by
notice to the insurer.
(C) This section shall not include the following types of
insurance or any combination thereof:
(1) Hospital indemnity.
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(2) Accident.
(3) Specified disease.
(4) Disability income.
(5) Dental.
(6) Vision.
(7) Civilian Health and Medical Program of the Uniformed
Services (CHAMPUS) supplement.
(8) Medicare supplement.
(9) Long-term care.
(10) Other limited benefit plans.
(11) Individual health insurance policies.
(D) For the purpose of this section:
"Health care insurance" means a group health, sickness or
accident policy or subscriber contract or certificate issued by
an entity subject to any one of the following:
(1) This act.
(2) The act of December 29, 1972 (P.L.1701, No.364), known
as the "Health Maintenance Organization Act."
(3) The act of May 18, 1976 (P.L.123, No.54), known as the
"Individual Accident and Sickness Insurance Minimum Standards
Act."
(4) 40 Pa.C.S. Ch. 61 (relating to hospital plan
corporations) or 63 (relating to professional health services
plan corporations).
(E) Employers shall not be required to contribute to any
increased premium charged by the insurer for the exercise of the
option provided under subsection (A), but the contributions may
be agreed to by the employer.
Section 3. The amendment or addition of sections 617(A)(3)
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
section.
Section 4. This act shall take effect in 60 days.
Section 1. The act of May 17, 1921 (P.L.682, No.284), known <--
as The Insurance Company Law of 1921, is amended by adding a
section to read:
Section 635.5. Access to Community Pharmacy Services.--(a)
With respect to prescription medications dispensed by a pharmacy
that agrees to participate in a provider network pursuant to
subsection (c), no health insurance policy, government program
or pharmacy benefit manager providing coverage or reimbursement
for the dispensing of prescription medications may as a
condition for the provision of benefits or for the payment of
reimbursement for medications or pharmacy services:
(1) require a covered individual to obtain any prescription
medication from a mail order pharmacy;
(2) impose upon a covered individual utilizing a retail
community pharmacy any copayment, deductible or other cost-
sharing requirement or prior authorization requirement not
imposed upon a covered individual utilizing a mail order
pharmacy;
(3) subject any medication dispensed by a retail community
pharmacy to a covered individual to a minimum or maximum
quantity limit, length of script, restriction on refills or
requirement to obtain refills not imposed upon a mail order
pharmacy;
(4) require a covered individual in whole or in part to pay
for any medication dispensed by a retail community pharmacy and
seek reimbursement when the individual is not required to pay
for and seek reimbursement in the same manner for a prescription
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dispensed by a mail order pharmacy;
(5) subject a covered individual to any administrative
requirement in order to use a retail community pharmacy that is
not imposed upon the use of a mail order pharmacy, including a
requirement to elect not to have a prescription dispensed by a
mail order pharmacy as a condition of utilizing a retail
community pharmacy; or
(6) impose any other term, condition or requirement
pertaining to the use of the services of a retail community
pharmacy that materially and unreasonably interferes with or
impairs the right of a covered individual to obtain prescription
medications from a retail community pharmacy of the individual's
choice.
(b) (1) No health insurance company, agent or contractor of
an insurance company, government program or pharmacy benefit
manager shall, in the administration of a health insurance
policy or a pharmacy provider network, take any action or allow
any action to occur that results in actions prohibited under
subsection (a).
(2) With respect to prescription medications dispensed by a
pharmacy eligible to participate in a provider network under
subsection (c), information regarding the dispensing of
prescription medications by a pharmacy shall not be used by a
health insurance company, an agent, affiliate or contractor of
an insurance company, a government program or by a prescription
benefit manager to promote, advertise or encourage the use of a
participating pharmacy, including a mail order pharmacy.
(c) (1) A pharmacy licensed and in good standing with the
State Board of Pharmacy, and not disqualified from participation
in the Medicaid or Medicare program for cause, shall have a
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right to participate in a pharmacy provider network, provided
the pharmacy offers to enter into an agreement accepting the
standard terms, conditions or requirements relating to
dispensing fees, payments for product costs and other pharmacy
services and the quality of dispensing and other pharmacy
services established by a health insurance company, government
program or pharmacy benefit manager for all pharmacies in the
provider network.
(2) The standard terms and conditions relating to dispensing
fees and payment for product costs and other pharmacy services
established under paragraph (1) shall provide convenient access
to retail community pharmacies consistent with the standards
established under section 2121 and taking into consideration the
standards established by the Center for Medicare and Medicaid
Services of the United States Department of Health and Human
Services pursuant to section 1395w-104(b)(1)(C) of the Social
Security Act (49 Stat. 620, 42 U.S.C. § 1395w-104(b)(1)(C)).
(3) The standard terms and conditions relating to dispensing
fees, ingredient costs and payments for pharmacy services
provided to retail community pharmacies shall not be less than
the amounts paid by or for the benefit of a health insurance
company, government program or pharmacy benefit manager for
dispensing of the same medications and the provision of
comparable services to any mail order pharmacy, including
amounts paid or distributed to a mail order pharmacy by an
affiliate of the mail order pharmacy or by the pharmacy benefit
manager.
(4) In determining whether the terms and conditions relating
to dispensing fees, ingredient costs and payments for pharmacy
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
practicable to any incentive payments received for the
dispensing of prescription medications by a mail order pharmacy
or an affiliate of a mail order pharmacy, including a pharmacy
benefit manager, from a pharmaceutical manufacturer or
distributor other than amounts paid for services provided to a
pharmaceutical manufacturer or distributor, or amounts used to
reduce the cost of prescription medication benefits paid by the
purchaser of a health insurance policy or the services of a
prescription drug manager, or by a government program.
(5) A pharmacy shall not be deemed to be eligible to
participate in a provider network under this subsection during
any period of time for which its right to participate in a
network has been suspended or revoked for serious violations of
a network pharmacy provider agreement established under this
subsection that reasonably warrant suspension or revocation.
(d) (1) With respect to a health insurance company or
pharmacy benefit manager:
(i) the department may utilize the enforcement mechanisms,
remedies and penalties available under section 628 and may
demand the production of any information necessary to enforce
this section; and
(ii) regardless of whether any enforcement action is taken
by the department, a covered individual, pharmacy or pharmacist
aggrieved by a violation of this section may seek relief to
remedy alleged violations of this section involving at least one
level of internal review and investigation in the manner
provided under section 2161(b) and an opportunity to appeal to
the department in the manner provided under section 2142 unless,
with respect to a pharmacy or pharmacist, an agreement with the
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insurance company or pharmacy benefit manager establishes an
alternative dispute resolution process in the manner provided
under section 2162(f).
(2) A covered individual, pharmacy or pharmacist aggrieved
by a violation of this section may petition the department to
review complaints regarding violations of this section.
(e) It is the intent of the General Assembly that this
section and the other provisions of Articles VI, VI-A, VI-B, X-A
and XII relating to health insurance shall, as applied to
persons subject to this act to the fullest extent possible, be
preserved from preemption by Federal law. In the event any
portion of this section or Article VI, VI-A, VI-B, X-A or XII
shall be preempted by Federal law or otherwise declared invalid
or unenforceable, the remaining provisions of such laws shall
remain in force and effect.
(f) As used in this section:
(1) "Covered individual" means an individual receiving
prescription medication coverage or reimbursement provided by a
health insurance policy, government program or pharmacy benefit
manager.
(2) "Government program" means any of the following:
(i) The Commonwealth's medical assistance program
established under the act of June 13, 1967 (P.L.31, No.21),
known as the "Public Welfare Code."
(ii) The adult basic coverage insurance program established
under Chapter 13 of the act of June 26, 2001 (P.L.755, No.77),
known as the "Tobacco Settlement Act."
(iii) The Children's Health Care Program established under
Article XXIII.
(iv) The program of pharmaceutical assistance for the
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elderly established by the act of August 26, 1971 (P.L.351,
No.91), known as the "State Lottery Law."
(v) An employe benefit plan described in section 1003(b)(1)
of the Employee Retirement Income Security Act of 1974 (Public
Law 93-46, 29 U.S.C. § 1003(b)(1)), applicable to government
employes who are residents of this Commonwealth.
(vi) Any other program established or operated by the
Commonwealth that provides or pays for the cost of prescription
medications and pharmacy services provided to residents of this
Commonwealth.
(3) "Health insurance company" means a fraternal benefit
society, health maintenance organization, hospital plan
corporation, insurer, preferred provider organization or
professional health services plan corporation as defined by
section 603-B, or other entity subject to this act.
(4) "Health insurance policy" means a group or individual
health or sickness or accident insurance policy, subscriber
contract or certificate issued by a health insurance company
providing coverage or benefits for prescription medications to
residents of this Commonwealth.
(5) "Mail order pharmacy" means a pharmacy that
predominantly receives prescriptions by mail, telefax or through
electronic submissions and predominantly dispenses the
medications to patients through the use of the United States
mail or other common or contract carrier delivery service and
generally provides consultations with patients electronically
rather than face-to-face.
(6) "Pharmacy benefit manager" means a person, partnership,
association or corporation not holding a certificate of
authority under section 630 that establishes, operates,
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maintains or administers agreements with pharmacies and health
insurance companies, government programs or employe benefit
plans described in section 1003(a) of the Employee Retirement
Income Security Act of 1974 relating to the dispensing of
prescription medications and the provision of pharmacy services
to covered individuals, including agreements relating to the
amounts to be charged by the pharmacy for services rendered,
incentives provided to covered individuals to use the services
of designated pharmacies, or limitations on reimbursement only
when services are provided by designated pharmacies.
(7) "Retail community pharmacy" means a pharmacy that is
open to the public, serves walk-in customers and makes available
face-to-face consultations between licensed pharmacists and
persons to whom medications are dispensed.
Section 2. The Insurance Department may adopt regulations to
administer and enforce section 635.5 of the act.
Section 3. Section 635.5 of the act shall apply to health
insurance policies, government programs and agreements with
pharmacy benefit managers that are offered, issued, executed or
renewed or that have provisions related to prescription
medication benefits that are amended on or after the effective
date of section 635.5 of the act.
Section 4. This act shall take effect as follows:
(1) The addition of section 635.5 of the act shall take
effect in 120 days.
(2) The remainder of this act shall take effect
immediately.
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