HB0273HCS

HOUSE HEALTH COMMITTEE SUBSTITUTE FOR

HOUSE BILL 273

52nd legislature - STATE OF NEW MEXICO - first session, 2015

AN ACT

RELATING TO HEALTH COVERAGE; ENACTING SECTIONS OF THE HEALTH CARE PURCHASING ACT, THE NEW MEXICO INSURANCE CODE, THE HEALTH MAINTENANCE ORGANIZATION LAW AND THE NONPROFIT HEALTH CARE PLAN LAW TO PROVIDE ENROLLEES WITH PARITY OF ACCESS AND LIMIT COST-SHARING DIFFERENTIALS FOR CERTAIN DRUGS BETWEEN PARTICIPATING MAIL-ORDER PHARMACIES AND PARTICIPATING COMMUNITY PHARMACIES.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:

SECTION 1. A new section of the Health Care Purchasing Act is enacted to read:

"[NEW MATERIAL] SPECIFIED PRESCRIPTION DRUGS--PARTICIPATING PHARMACIES--ACCESS PARITY--COST-SHARING LIMITS.--

A. As of January 1, 2017, group health coverage, including any form of self-insurance, offered, issued or renewed under the Health Care Purchasing Act, that offers a prescription drug or device benefit shall permit an enrollee to fill a specified covered prescription at the enrollee's option at any participating community pharmacy or participating mail-order pharmacy; provided that the participating community pharmacy accepts reimbursement at a rate equal to that of a participating mail-order pharmacy.

B. When an enrollee fills a specified covered prescription at a participating community pharmacy, a group health plan shall not impose a copayment, coinsurance or other cost-sharing condition at a rate that exceeds one hundred fifty percent of any copayment, coinsurance or other cost-sharing condition imposed on a specified covered prescription filled at a participating mail-order pharmacy.

C. Nothing in this section shall prohibit a manufacturer from placing a specialty drug in a limited distributed network, including the use of one or more specialty pharmacies.

D. As used in this section:

(1) "participating community pharmacy" means a retail pharmacy:

(a) for which a majority of the pharmacy's business in the state is not conducted as a mail-order pharmacy; and

(b) that has agreed to accept a group health plan's contracted payment rate, and, pursuant to this agreement, an enrollee may fill a prescription and pay a copayment or coinsurance that is more advantageous to the enrollee than the copayment or coinsurance for a prescription sought from a retail pharmacy that has not agreed to the group health plan's contracted payment rate;

(2) "participating mail-order pharmacy" means a retail pharmacy:

(a) located in the United States;

(b) for which the majority of the pharmacy's business consists of dispensing a prescription drug or device under a prescription drug order and having the drug or device delivered to a patient by the United States mail, a common carrier or a delivery service. Mail-order pharmacies include, but are not limited to, pharmacies that do business via the internet or other electronic media; and

(c) that has agreed to accept a group health plan's contracted payment rate, and, pursuant to this agreement, an enrollee may fill a prescription and pay a copayment or coinsurance that is more advantageous to the enrollee than the copayment or coinsurance for a prescription sought from a retail pharmacy that has not agreed to the group health plan's contracted payment rate;

(3) "specialty drug" means a drug that:

(a) is structurally complex;

(b) is used to treat a complex chronic condition or a rare condition;

(d) involves a significant degree of patient education and monitoring to minimize adverse events; and

(e) requires expert medical management to optimize health outcomes; and

(4) "specified covered prescription" means a drug, for which a group health plan has agreed to make reimbursement under the terms of the group health plan, to treat any of the following conditions:

(a) cancer;

(b) hepatitis A, B or C;

(d) multiple sclerosis; or

(e) an autoimmune disorder."

SECTION 2. A new section of Chapter 59A, Article 22 NMSA 1978 is enacted to read:

"[NEW MATERIAL] SPECIFIED PRESCRIPTION DRUGS--PARTICIPATING PHARMACIES--ACCESS PARITY--COST-SHARING LIMITS.--

A. As of January 1, 2017, an individual health insurance policy, health care plan or certificate of health insurance that is delivered, issued for delivery or renewed in this state and that provides a prescription drug or device benefit shall permit an insured to fill a specified covered prescription at the insured's option at any participating community pharmacy or participating mail-order pharmacy; provided that the participating community pharmacy accepts reimbursement at a rate equal to that of a participating mail-order pharmacy.

B. When an insured fills a specified covered prescription at a participating community pharmacy, an insurer shall not impose a copayment, coinsurance or other cost-sharing condition at a rate that exceeds one hundred fifty percent of any copayment, coinsurance or other cost-sharing condition imposed on a specified covered prescription filled at a participating mail-order pharmacy.

C. Nothing in this section shall prohibit a manufacturer from placing a specialty drug in a limited distributed network, including the use of one or more specialty pharmacies.

D. As used in this section:

(1) "participating community pharmacy" means a retail pharmacy:

(a) for which a majority of the pharmacy's business in the state is not conducted as a mail-order pharmacy; and

(b) that has agreed to accept an insurer's contracted payment rate, and, pursuant to this agreement, an insured may fill a prescription and pay a copayment or coinsurance that is more advantageous to the insured than the copayment or coinsurance for a prescription sought from a retail pharmacy that has not agreed to the insurer's contracted payment rate;

(2) "participating mail-order pharmacy" means a retail pharmacy:

(a) located in the United States;

(c) that has agreed to accept an insurer's contracted payment rate, and, pursuant to this agreement, an insured may fill a prescription and pay a copayment or coinsurance that is more advantageous to the insured than the copayment or coinsurance for a prescription sought from a retail pharmacy that has not agreed to the insurer's contracted payment rate;

(3) "specialty drug" means a drug that:

(a) is structurally complex;

(b) is used to treat a complex chronic condition or a rare condition;

(d) involves a significant degree of patient education and monitoring to minimize adverse events; and

(e) requires expert medical management to optimize health outcomes; and

(4) "specified covered prescription" means a drug, for which an insurer has agreed to make reimbursement under the terms of the individual policy, plan or certificate, to treat any of the following conditions:

(a) cancer;

(b) hepatitis A, B or C;

(d) multiple sclerosis; or

(e) an autoimmune disorder."

SECTION 3. A new section of Chapter 59A, Article 23 NMSA 1978 is enacted to read:

"[NEW MATERIAL] SPECIFIED PRESCRIPTION DRUGS--PARTICIPATING PHARMACIES--ACCESS PARITY--COST-SHARING LIMIT.--

A. As of January 1, 2017, a group or blanket health insurance policy, health care plan or certificate of health insurance that is delivered, issued for delivery or renewed in this state and that provides a prescription drug or device benefit shall permit an insured to fill a specified covered prescription at the insured's option at any participating community pharmacy or participating mail-order pharmacy; provided that the participating community pharmacy accepts reimbursement at a rate equal to that of a participating mail-order pharmacy.

C. Nothing in this section shall prohibit a manufacturer from placing a specialty drug in a limited distributed network, including the use of one or more specialty pharmacies.

D. As used in this section:

(1) "participating community pharmacy" means a retail pharmacy:

(a) for which a majority of the pharmacy's business in the state is not conducted as a mail-order pharmacy; and

(b) that has agreed to accept a insurer's contracted payment rate, and, pursuant to this agreement, an insured may fill a prescription and pay a copayment or coinsurance that is more advantageous to the insured than the copayment or coinsurance for a prescription sought from a retail pharmacy that has not agreed to the insurer's contracted payment rate;

(2) "participating mail-order pharmacy" means a retail pharmacy:

(a) located in the United States;

(3) "specialty drug" means a drug that:

(a) is structurally complex;

(b) is used to treat a complex chronic condition or a rare condition;

(d) involves a significant degree of patient education and monitoring to minimize adverse events; and

(e) requires expert medical management to optimize health outcomes; and

(4) "specified covered prescription" means a drug, for which an insurer has agreed to make reimbursement under the terms of a group or blanket policy, plan or certificate, to treat any of the following conditions:

(a) cancer;

(b) hepatitis A, B or C;

(d) multiple sclerosis; or

(e) an autoimmune disorder."

SECTION 4. A new section of the Health Maintenance Organization Law is enacted to read:

"[NEW MATERIAL] SPECIFIED PRESCRIPTION DRUGS--PARTICIPATING PHARMACIES--ACCESS PARITY--COST-SHARING LIMITS.--

A. As of January 1, 2017, an individual or group health maintenance organization contract that is delivered, issued for delivery or renewed in this state and that provides a prescription drug or device benefit shall permit an enrollee to fill a specified covered prescription at the enrollee's option at any participating community pharmacy or participating mail-order pharmacy; provided that the participating community pharmacy accepts reimbursement at a rate equal to that of a participating mail-order pharmacy.

B. When an enrollee fills a specified covered prescription at a participating community pharmacy, a health maintenance organization shall not impose a copayment, coinsurance or other cost-sharing condition at a rate that exceeds one hundred fifty percent of any copayment, coinsurance or other cost-sharing condition imposed on a specified covered prescription filled at a participating mail-order pharmacy.

C. Nothing in this section shall prohibit a manufacturer from placing a specialty drug in a limited distributed network, including the use of one or more specialty pharmacies.

D. As used in this section:

(1) "participating community pharmacy" means a retail pharmacy:

(a) for which a majority of the pharmacy's business in the state is not conducted as a mail-order pharmacy; and

(b) that has agreed to accept a health maintenance organization's contracted payment rate, and, pursuant to this agreement, an enrollee may fill a prescription and pay a copayment or coinsurance that is more advantageous to the enrollee than the copayment or coinsurance for a prescription sought from a retail pharmacy that has not agreed to the health maintenance organization's contracted payment rate;

(2) "participating mail-order pharmacy" means a retail pharmacy:

(a) located in the United States;

(c) that has agreed to accept a health maintenance organization's contracted payment rate, and, pursuant to this agreement, an enrollee may fill a prescription and pay a copayment or coinsurance that is more advantageous to the enrollee than the copayment or coinsurance for a prescription sought from a retail pharmacy that has not agreed to the health maintenance organization's contracted payment rate;

(3) "specialty drug" means a drug that:

(a) is structurally complex;

(b) is used to treat a complex chronic condition or a rare condition;

(d) involves a significant degree of patient education and monitoring to minimize adverse events; and

(e) requires expert medical management to optimize health outcomes; and

(4) "specified covered prescription" means a drug, for which a health maintenance organization has agreed to make reimbursement under the terms of a contract, to treat any of the following conditions:

(a) cancer;

(b) hepatitis A, B or C;

(d) multiple sclerosis; or

(e) an autoimmune disorder."

SECTION 5. A new section of the Nonprofit Health Care Plan Law is enacted to read:

"[NEW MATERIAL] SPECIFIED PRESCRIPTION DRUGS--PARTICIPATING PHARMACIES--ACCESS PARITY--COST-SHARING LIMITS.--

A. An individual or group health care plan that is delivered, issued for delivery or renewed in this state and that provides a prescription drug or device benefit shall permit a subscriber to fill a specified covered prescription at the subscriber's option at any participating community pharmacy or participating mail-order pharmacy; provided that the participating community pharmacy accepts reimbursement at a rate equal to that of a participating mail-order pharmacy.

B. When a subscriber fills a specified covered prescription at a participating community pharmacy, a health care plan shall not impose a copayment, coinsurance or other cost-sharing condition at a rate that exceeds one hundred fifty percent of any copayment, coinsurance or other cost-sharing condition imposed on a specified covered prescription filled at a participating mail-order pharmacy.

C. Nothing in this section shall prohibit a manufacturer from placing a specialty drug in a limited distributed network, including the use of one or more specialty pharmacies.

D. As used in this section:

(1) "participating community pharmacy" means a retail pharmacy:

(a) for which a majority of the pharmacy's business in the state is not conducted as a mail-order pharmacy; and

(b) that has agreed to accept a health care plan's contracted payment rate, and, pursuant to this agreement, a subscriber may fill a prescription and pay a copayment or coinsurance that is more advantageous to the subscriber than the copayment or coinsurance for a prescription sought from a retail pharmacy that has not agreed to the health care plan's contracted payment rate;

(2) "participating mail-order pharmacy" means a retail pharmacy:

(a) located in the United States;

(b) for which the majority of the pharmacy's business consists of dispensing a prescription drug or device under a prescription drug order and having the drug or device delivered to a subscriber by the United States mail, a common carrier or a delivery service. Mail-order pharmacies include, but are not limited to, pharmacies that do business via the internet or other electronic media; and

(c) that has agreed to accept a health care plan's contracted payment rate, and, pursuant to this agreement, a subscriber may fill a prescription and pay a copayment or coinsurance that is more advantageous to the subscriber than the copayment or coinsurance for a prescription sought from a retail pharmacy that has not agreed to the health care plan's contracted payment rate;

(3) "specialty drug" means a drug that:

(a) is structurally complex;

(b) is used to treat a complex chronic condition or a rare condition;

(d) involves a significant degree of patient education and monitoring to minimize adverse events; and

(e) requires expert medical management to optimize health outcomes; and

(4) "specified covered prescription" means a drug, for which a health care plan has agreed to make reimbursement under the terms of the health care plan, to treat any of the following conditions:

(a) cancer;

(b) hepatitis A, B or C;

(d) multiple sclerosis; or

(e) an autoimmune disorder."

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