Florida Senate - 2015 COMMITTEE AMENDMENT
Bill No. SB 860
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LEGISLATIVE ACTION
Senate . House
Comm: RCS .
03/23/2015 .
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The Committee on Banking and Insurance (Montford) recommended
the following:
1 Senate Amendment (with title amendment)
2
3 Delete everything after the enacting clause
4 and insert:
5 Section 1. Section 465.1862, Florida Statutes, is created
6 to read:
7 465.1862 Pharmacy benefit managers.—
8 (1) As used in this section, the term:
9 (a) “Contracted pharmacy” means a pharmacy or network of
10 pharmacies which has executed a contract that includes maximum
11 allowable cost pricing requirements with a pharmacy benefit
12 manager that acts on behalf of a plan sponsor.
13 (b) “Maximum allowable cost” means the upper limit or
14 maximum amount that a plan sponsor will pay for a generic
15 prescription drug or a brand-name prescription drug with an
16 available generic version, which is included on a list of
17 products generated by the pharmacy benefit manager.
18 (c) “Pharmacy benefit manager” means a person, business, or
19 other entity that provides administrative services related to
20 processing and paying prescription claims for pharmacy benefit
21 and coverage programs. Such services may include, but are not
22 limited to, contracting with a pharmacy or network of
23 pharmacies; establishing payment levels for pharmacies;
24 dispensing prescription drugs to plan sponsor beneficiaries;
25 negotiating discounts and rebate arrangements with drug
26 manufacturers; developing and managing prescription formularies,
27 preferred drug lists, and prior authorization programs; ensuring
28 audit compliance; and providing management reports.
29 (d) “Plan sponsor” means a health maintenance organization,
30 an insurer, except for an insurer that issues casualty insurance
31 as defined in s. 624.605, a Medicaid managed care plan as
32 defined in s. 409.962(9), a prepaid limited health service
33 organization, or other entity contracting for pharmacy benefit
34 manager services.
35 (2) A contract between a pharmacy benefit manager and a
36 contracted pharmacy must require the pharmacy benefit manager to
37 update the maximum allowable cost pricing information at least
38 every 7 calendar days and must establish a reasonable process
39 for the prompt notification of any pricing update to the
40 contracted pharmacy.
41 (3) A pharmacy benefit manager, to place a prescription
42 drug on a maximum allowable cost pricing list, at a minimum,
43 must ensure that the drug has at least two or more nationally
44 available, therapeutically equivalent, multiple-source generic
45 drugs that:
46 (a) Have a significant cost difference.
47 (b) Are listed as therapeutically and pharmaceutically
48 equivalent or “A” or “AB” rated in the Orange Book: Approved
49 Drug Products with Therapeutic Equivalence Evaluations published
50 by the United States Food and Drug Administration as of July 1,
51 2015.
52 (c) Are available for purchase from national or regional
53 wholesalers without limitation by all pharmacies in the state.
54 (d) Are not obsolete or temporarily unavailable.
55 (4) In a contract between a pharmacy benefit manager and a
56 plan sponsor, the pharmacy benefit manager must disclose to the
57 plan sponsor whether the pharmacy benefit manager uses a maximum
58 allowable cost pricing list for drugs dispensed at retail but
59 does not use such a list for drugs dispensed by mail order. If
60 such practice is adopted after a contract is executed, the
61 pharmacy benefit manager shall disclose such practice to the
62 plan sponsor within 21 business days after implementation of the
63 practice.
64 (5)(a) Each contract between a pharmacy benefit manager and
65 a contracted pharmacy must include a process for appeal,
66 investigation, and resolution of disputes regarding maximum
67 allowable cost pricing. The process must:
68 1. Limit the right to appeal to 30 calendar days after an
69 initial claim is made by the contracted pharmacy.
70 2. Require investigation and resolution of a dispute within
71 14 days after an appeal is received by the pharmacy benefit
72 manager.
73 3. Include a telephone number at which a contracted
74 pharmacy may contact the pharmacy benefit manager regarding an
75 appeal.
76 (b) If an appeal is denied, the pharmacy benefit manager
77 shall provide the reasons for denial and shall identify the
78 national drug code for the prescription drug that may be
79 purchased by the contracted pharmacy at a price at or below the
80 disputed maximum allowable cost pricing.
81 (c) If an appeal is upheld, the pharmacy benefit manager
82 shall adjust the maximum allowable cost pricing retroactive to
83 the date that the claim was adjudicated. The pharmacy benefit
84 manager shall apply the adjustment retroactively to any
85 similarly situated contracted pharmacy.
86 Section 2. This act shall take effect July 1, 2015.
87
88 ================= T I T L E A M E N D M E N T ================
89 And the title is amended as follows:
90 Delete everything before the enacting clause
91 and insert:
92 A bill to be entitled
93 An act relating to pharmacy; creating s. 465.1862,
94 F.S.; defining terms; providing requirements for
95 contracts between pharmacy benefit managers and
96 contracted pharmacies; requiring a pharmacy benefit
97 manager to ensure that a prescription drug has met
98 certain requirements to be placed on a maximum
99 allowable cost pricing list; requiring the pharmacy
100 benefit manager to disclose certain information to a
101 plan sponsor; requiring a contract between a pharmacy
102 benefit manager and a pharmacy to include an appeal
103 process; providing an effective date.