First Regular Session Seventieth General Assembly STATE OF COLORADO INTRODUCED LLS NO. 15-0365.01 Christy Chase x2008 SENATE BILL 15-123 SENATE SPONSORSHIP Crowder, HOUSE SPONSORSHIP Primavera, Senate Committees House Committees Health & Human Services A BILL FOR AN ACT Concerning the ability of a person eligible for prescription drug benefits under a health benefit plan to choose the pharmacy at which to fill a prescription drug order for certain medications. Bill Summary (Note: This summary applies to this bill as introduced and does not reflect any amendments that may be subsequently adopted. If this bill passes third reading in the house of introduction, a bill summary that applies to the reengrossed version of this bill will be available at http://www.leg.state.co.us/billsummaries.) Pharmacy benefit management firms (PBM) that administer prescription drug benefits and carriers, under the terms of the health benefit plans offering prescription drug benefits, may require a person who is eligible for prescription drug benefits to fill a prescription drug order through either a mail-order pharmacy or another pharmacy designated by the PBM or carrier. The bill allows a covered person who receives a prescription order for a specialty drug or biological product to fill the prescription order at a network pharmacy chosen by the covered person if the covered person properly notifies the PBM or carrier. For proper notification, the covered person must include in the notice an attestation from the chosen local pharmacy that the pharmacy: Is able to comply with applicable state and federal laws and the requirements of the manufacturer and the U.S. Pharmacopeial Convention for the particular medication; and Accepts the payment terms for specialty drugs and biological products provided under the applicable health benefit plan to existing network pharmacies. The PBM or carrier must pay claims for specialty drugs or biological products timely and in the same manner as it pays claims for other prescriptions. A PBM or carrier is prohibited from: Imposing different payment terms than those imposed when a covered person fills a prescription for a specialty drug or biological product at a mail-order or other designated pharmacy; or Providing an incentive for a covered person to fill a specialty drug or biological product prescription at a mail-order or other designated pharmacy. Violation of the requirements of the bill constitutes an unfair or deceptive act or practice in the business of insurance. Be it enacted by the General Assembly of the State of Colorado: SECTION 1. In Colorado Revised Statutes, add 10-16-142 as follows: 10-16-142. Patient choice of pharmacy - notice to carrier or pharmacy benefit management firm - prohibited practices - rules. (1) (a) If a covered person is required, either by a pharmacy benefit management firm that manages the covered person's prescription drug benefits or under the terms of the health benefit plan that provides prescription drug benefits to the covered person, to fill a prescription order for a specialty drug or biological product at a mail order specialty pharmacy, specialty network pharmacy, or other pharmacy designated by the pharmacy benefit management firm or health benefit plan that is not the covered person's preferred pharmacy, the covered person has the right to obtain the specialty drug or biological product at a network pharmacy selected by the covered person if the covered person properly notifies the pharmacy benefit management firm or carrier that issued the health benefit plan. A covered person properly notifies a pharmacy benefit management firm or carrier by submitting a notification containing the attestation specified in paragraph (b) of this subsection (1) by: Telephone, facsimile, or electronic mail; via a web site; or by other electronic means. (b) The notification must contain an attestation from the pharmacy at which the covered person elects to fill a prescription order for a specialty drug or biological product that: (I) The pharmacy is able to comply with the requirements of state and federal law, the specialty drug or biological product manufacturer, and the United States Pharmacopeial Convention for the prescribed specialty drug or biological product; and (II) The pharmacy accepts the payment terms for specialty drug or biological product prescriptions that are provided under the applicable health benefit plan to existing specialty network pharmacies. (2) The pharmacy benefit management firm or carrier shall process and pay claims for covered specialty drugs or biological products timely and in the same manner as it processes and pays claims for other prescriptions filled by the pharmacy. (3) If the pharmacy benefit management firm or carrier receives proper notification from a covered person for a particular pharmacy to fill a prescription order for a specialty drug or biological product for the covered person, the pharmacy is authorized to fill prescriptions for the specialty drug or biological product for any patient under the plan without the need for further notification or attestations. (4) If a covered person properly notifies the pharmacy benefit management firm or carrier and fills a prescription order for a specialty drug or biological product at the network pharmacy of his or her choice, the pharmacy benefit management firm or carrier shall charge neither premium, copayment, deductible, coinsurance, or maximum out-of-pocket amounts nor or other payment terms that: (a) Differ from those charged to the covered person for using a mail order specialty pharmacy, specialty network pharmacy, or other designated pharmacy; or (b) Provide an incentive to the covered person to use a mail order specialty pharmacy, specialty network pharmacy, or other designated pharmacy to fill a prescription order for a specialty drug or biological product. (5) Every pharmacy benefit management firm or carrier that provides prescription drug benefits shall notify every covered person eligible for prescription drug benefits that the covered person has the right to fill his or her prescription orders for specialty drugs or biological products at a qualified local pharmacy of the covered person's choice rather than at a mail order specialty pharmacy, specialty network pharmacy, or other pharmacy designated by the pharmacy benefit management firm or carrier. The pharmacy benefit management firm or carrier shall include the notice, which must be clearly stated, in the pharmacy network contract and in each explanation of benefits. A pharmacist may also inform the covered person of his or her rights under this section. (6) The commissioner shall adopt rules for the implementation and enforcement of this section. (7) As used in this section, "biological product" has the same meaning as set forth in 42 U.S.C. sec. 262 (i) (1). SECTION 2. In Colorado Revised Statutes, 10-3-1104, amend (1) (qq); and add (1) (ss) as follows: 10-3-1104. Unfair methods of competition - unfair or deceptive acts or practices - repeal. (1) The following are defined as unfair methods of competition and unfair or deceptive acts or practices in the business of insurance: (qq) Failure to pay a final, nonappealable judgment award for failure to return or repay collateral received to secure a bond; or (ss) Violating section 10-16-142. SECTION 3. Act subject to petition - effective date. This act takes effect at 12:01 a.m. on the day following the expiration of the ninety-day period after final adjournment of the general assembly (August 5, 2015, if adjournment sine die is on May 6, 2015); except that, if a referendum petition is filed pursuant to section 1 (3) of article V of the state constitution against this act or an item, section, or part of this act within such period, then the act, item, section, or part will not take effect unless approved by the people at the general election to be held in November 2016 and, in such case, will take effect on the date of the official declaration of the vote thereon by the governor.