Bill Text: OR SB372 | 2013 | Regular Session | Introduced

Oregon Senate Bill 372 (Prior Session Legislation)

Bill Title: Relating to pharmacy benefit managers.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Failed) 2013-07-08 - In committee upon adjournment. [SB372 Detail]

Download: Oregon-2013-SB372-Introduced.html



     77th OREGON LEGISLATIVE ASSEMBLY--2013 Regular Session

NOTE:  Matter within  { +  braces and plus signs + } in an
amended section is new. Matter within  { -  braces and minus
signs - } is existing law to be omitted. New sections are within
 { +  braces and plus signs + } .

LC 1618

                         Senate Bill 372

Sponsored by Senator BATES (Presession filed.)

                             SUMMARY

The following summary is not prepared by the sponsors of the
measure and is not a part of the body thereof subject to
consideration by the Legislative Assembly. It is an editor's
brief statement of the essential features of the measure as
introduced.

  Requires Department of Consumer and Business Services to
require pharmacy benefit managers to meet specified requirements.

                        A BILL FOR AN ACT
Relating to pharmacy benefit managers.
Be It Enacted by the People of the State of Oregon:
  SECTION 1.  { + Section 2 of this 2013 Act is added to and made
a part of the Insurance Code. + }
  SECTION 2.  { + (1) As used in this section:
  (a) 'List' means the list of drugs for which a pharmacy benefit
manager has established maximum allowable costs.
  (b) 'Maximum allowable cost' means the maximum amount that a
pharmacy benefit manager will pay toward the cost of a drug.
  (c) 'Nationally available' means that all pharmacies in this
state can purchase the drug, without limitation, from regional or
national wholesalers and that the product is not obsolete or
temporarily available.
  (d) 'Pharmacy benefit manager' means a third party
administrator that contracts with an insurer or a self-insured
employer to process claims for the reimbursement of the costs of
prescription drugs.
  (e) 'Therapeutically equivalent' means the drug is identified
as therapeutically or pharmaceutically equivalent or ' A' rated
by the United States Food and Drug Administration.
  (2) The Department of Consumer and Business Services shall
adopt rules governing the following activities by pharmacy
benefit managers:
  (a) Claims processing.
  (b) Retail pharmacy network management.
  (c) Pharmacy discount card management.
  (d) Payment of claims to pharmacies for prescription drugs
dispensed to insureds.
  (e) Clinical formulary development and management services,
including, but not limited to, utilization management and quality
assurance programs.
  (f) Rebate contracting and administration.
  (g) Audits of contracted pharmacies.
  (h) Establishment of pharmacy reimbursement pricing and
methodologies, including maximum allowable cost.
  (i) Retention of any difference between what is received from
insurers or self-insured employers as reimbursement for
prescription drugs and what is paid to a pharmacy by the pharmacy
benefit manager for such drugs.
  (3)(a) In any contract between a pharmacy benefit manager and a
pharmacy, the pharmacy benefit manager shall:
  (A) Specify the methodology and sources used to determine
maximum allowable costs;
  (B) Set forth an administrative appeal procedure that a
pharmacy may use to contest the maximum allowable cost and that
ensures that the pharmacy benefit manager will make a
determination no later than 15 days after the pharmacy initiates
the appeal; and
  (C) Specify the process for making changes to the list or
changes to the maximum allowable cost for any drug on the list.
  (b) If a pharmacy contests a maximum allowable cost under
paragraph (a)(B) of this subsection and the pharmacy benefit
manager adjusts the maximum allowable cost for a drug or removes
the drug from the list, the pharmacy benefit manager shall apply
the adjustment to all pharmacies contracting with the pharmacy
benefit manager and shall retroactively apply the new
reimbursement rate to the date that the pharmacy dispensed the
drug that was the subject of the contested claim.
  (c) A pharmacy benefit manager that contracts with an insurer
or a self-insured employer to process claims for prescription
drugs:
  (A) May not include a drug on the list unless there are at
least three nationally available, therapeutically equivalent
drugs available for purchase at a significant cost difference;
  (B) Shall update the maximum allowable cost for drugs on the
list no less than once every seven calendar days and shall
promptly notify pharmacies, insurers and self-insured employers
of any changes;
  (C) Shall establish a procedure for removing drugs from the
list in a timely manner;
  (D) May not add a drug to the list or must promptly remove a
drug from the list if the criteria of paragraph (a) of this
subsection are not met with respect to the drug;
  (E) Shall inform the insurer or self-insured employer if the
pharmacy benefit manager applies a maximum allowable cost to
drugs dispensed through a pharmacy but not through a mail order
service; and
  (F) Shall notify the insurer or self-insured employer if the
pharmacy benefit manager does not use the same list for billing
the insurer or self-insured employer as it uses in reimbursing
pharmacies. If there is a difference between the list used for
billing an insurer or a self-insured employer and the list used
for reimbursing pharmacies, the pharmacy benefit manager shall
inform the insurer or self-insured employer of the difference
between the maximum allowable cost charged to the insurer or
self-insured employer and the maximum allowable cost paid to a
pharmacy. + }
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