HB0273

HOUSE BILL 273

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

INTRODUCED BY

Deborah A. Armstrong

AN ACT

RELATING TO HEALTH COVERAGE; ENACTING SECTIONS OF THE HEALTH CARE PURCHASING ACT, THE PUBLIC ASSISTANCE 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 PAYMENT 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] PHARMACY BENEFITS--PARTICIPATING PHARMACIES--ACCESS PARITY--COPAYMENT AND COINSURANCE PARITY.--

A. 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 covered prescription at his or her option at any participating community pharmacy or participating mail-order pharmacy; provided that the participating community pharmacy accepts reimbursement at a rate comparable to that of a participating mail-order pharmacy.

B. A group health plan shall not impose a copayment, coinsurance or other condition on an enrollee who elects to fill a covered prescription from a participating community pharmacy that is not also imposed on an enrollee who elects to fill a covered prescription at a participating mail-order pharmacy.

C. As used in this section:

(1) "covered prescription" means a drug or device for which a group health plan has agreed to make reimbursement under the terms of the group health plan;

(2) "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; and

(3) "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."

SECTION 2. A new section of the Public Assistance Act is enacted to read:

"[NEW MATERIAL] MEDICAL ASSISTANCE--PHARMACY BENEFITS--PARTICIPATING PHARMACIES--ACCESS PARITY--COPAYMENT AND COINSURANCE PARITY.--

A. The secretary shall adopt and promulgate rules to provide that a prescription drug or device benefit provided to medical assistance recipients shall permit a recipient to fill a covered prescription at his or her option at any participating community pharmacy or participating mail-order pharmacy; provided that the participating community pharmacy accepts reimbursement at a rate comparable to that of a participating mail-order pharmacy.

B. A medical assistance program or a managed care plan shall not impose a copayment, coinsurance or other condition on a recipient who elects to fill a covered prescription from a participating community pharmacy that is not also imposed on a recipient who elects to fill a covered prescription at a participating mail-order pharmacy.

C. As used in this section:

(1) "covered prescription" means a drug or device for which a medical assistance program or managed care plan has agreed to make reimbursement under the terms of the medical assistance program or managed care plan;

(2) "managed care plan" means health coverage offered by person eligible to enter into risk-based prepaid capitation agreements with the department pursuant to a state medical assistance program;

(3) "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 medical assistance program's or managed care plan's contracted payment rate, and, pursuant to this agreement, a recipient may fill a prescription and pay a copayment or coinsurance that is more advantageous to the recipient than the copayment or coinsurance for a prescription sought from a retail pharmacy that has not agreed to the medical assistance program's or managed care plan's contracted payment rate; and

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

(a) located in the United States;

(c) that has agreed to accept a medical assistance program's or managed care plan's contracted payment rate, and, pursuant to this agreement, a recipient may fill a prescription and pay a copayment or coinsurance that is more advantageous to the recipient than the copayment or coinsurance for a prescription sought from a retail pharmacy that has not agreed to the medical assistance program's or managed care plan's contracted payment rate."

SECTION 3. A new section of Chapter 59A, Article 22 NMSA 1978 is enacted to read:

"[NEW MATERIAL] PHARMACY BENEFITS--PARTICIPATING PHARMACIES--ACCESS PARITY--COPAYMENT AND COINSURANCE PARITY.--

A. 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 covered prescription at his or her option at any participating community pharmacy or participating mail-order pharmacy; provided that the participating community pharmacy accepts reimbursement at a rate comparable to that of a participating mail-order pharmacy.

B. An insurer shall not impose a copayment, coinsurance or other condition on an insured who elects to fill a covered prescription from a participating community pharmacy that is not also imposed on an insured who elects to fill a covered prescription at a participating mail-order pharmacy.

C. As used in this section:

(1) "covered prescription" means a drug or device for which a group health plan has agreed to make reimbursement under the terms of the policy, plan or certificate;

(2) "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; and

(3) "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."

SECTION 4. A new section of Chapter 59A, Article 23 NMSA 1978 is enacted to read:

"[NEW MATERIAL] PHARMACY BENEFITS--PARTICIPATING PHARMACIES--ACCESS PARITY--COPAYMENT AND COINSURANCE PARITY.--

A. 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 covered prescription at his or her option at any participating community pharmacy or participating mail-order pharmacy; provided that the participating community pharmacy accepts reimbursement at a rate comparable to that of a participating mail-order pharmacy.

C. As used in this section:

(1) "covered prescription" means a drug or device for which a group health plan has agreed to make reimbursement under the terms of the group health plan;

(2) "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; and

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

(a) located in the United States;

SECTION 5. A new section of the Health Maintenance Organization Law is enacted to read:

"[NEW MATERIAL] PHARMACY BENEFITS--PARTICIPATING PHARMACIES--ACCESS PARITY--COPAYMENT AND COINSURANCE PARITY.--

A. 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 covered prescription at his or her option at any participating community pharmacy or participating mail-order pharmacy; provided that the participating community pharmacy accepts reimbursement at a rate comparable to that of a participating mail-order pharmacy.

B. A health maintenance organization shall not impose a copayment, coinsurance or other condition on an enrollee who elects to fill a covered prescription from a participating community pharmacy that is not also imposed on an enrollee who elects to fill a covered prescription at a participating mail-order pharmacy.

C. As used in this section:

(1) "covered prescription" means a drug or device for which a group health plan has agreed to make reimbursement under the terms of the group health plan;

(2) "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; and

(3) "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."

SECTION 6. A new section of the Nonprofit Health Care Plan Law is enacted to read:

"[NEW MATERIAL] PHARMACY BENEFITS--PARTICIPATING PHARMACIES--ACCESS PARITY--COPAYMENT AND COINSURANCE PARITY.--

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 covered prescription at his or her option at any participating community pharmacy or participating mail-order pharmacy; provided that the participating community pharmacy accepts reimbursement at a rate comparable to that of a participating mail-order pharmacy.

B. A health care plan shall not impose a copayment, coinsurance or other condition on a subscriber who elects to fill a covered prescription from a participating community pharmacy that is not also imposed on a subscriber who elects to fill a covered prescription at a participating mail-order pharmacy.

C. As used in this section:

(1) "covered prescription" means a drug or device for which a group health plan has agreed to make reimbursement under the terms of the group health plan;

(2) "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; and

(3) "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."

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