Bill Summary – FastDemocracy

LB109                                                                              LB109
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                                LEGISLATURE OF NEBRASKA
                            ONE HUNDRED NINTH LEGISLATURE
                                     FIRST SESSION
                         LEGISLATIVE BILL 109
        Introduced by Bostar, 29.
        Read first time January 10, 2025
        Committee: Banking, Commerce and Insurance
    A BILL FOR AN ACT relating to insurance; to amend sections 44-4606 and
        44-4610, Revised Statutes Cumulative Supplement, 2024; to prohibit
        certain provisions in insurance policies and health plans relating
        to clinician-administered drugs;   to prohibit pharmacy benefit
       managers from taking certain actions; to change provisions relating
       to   a pharmacy benefit manager's specialty pharmacy network;   to
       provide severability; and to repeal the original sections.
   Be it enacted by the people of the State of Nebraska,
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        Section 1.        (1) Notwithstanding section 44-3,131, any individual or
    group sickness and accident insurance policy, certificate, or subscriber
   contract delivered, issued for delivery, or renewed in this state and any
   hospital,    medical,      or surgical expense-incurred policy,    except for
   policies that provide coverage for a specified disease or other limited-
   benefit coverage, any self-funded employee benefit plan to the extent not
   preempted by federal law, and any pharmacy benefit manager as defined in
   section 44-4603, shall not:
       (a) Refuse to authorize, approve, or pay a participating provider
    for providing covered clinician-administered drugs and related services
    to covered persons;
       (b) Impose coverage or benefit limitations or require an enrollee to
   pay an additional fee, higher copay, higher coinsurance, second copay,
   second coinsurance,          or other penalty when obtaining clinician-
   administered drugs from a health care provider authorized under the laws
   of this state to administer clinician-administered drugs or a pharmacy;
       (c) Interfere with the right of a patient to choose to obtain a
   clinician-administered drug from such patient's provider such as through
   inducement, steering, or offering financial or other incentives;
       (d)     Require clinician-administered drugs to    be dispensed by   a
   pharmacy selected by the insurer;
       (e) Limit or exclude coverage for a clinician-administered drug when
   such drug is not dispensed by a pharmacy selected by the health plan if
   such drug would otherwise be covered;
       (f)     Reimburse at   a lesser amount     a clinician-administered drug
   dispensed by a pharmacy not selected by the insurer or acquired from an
   entity not selected by the insurer;
       (g) Condition, deny, restrict, refuse to authorize or approve, or
    reduce payment to    a participating provider for providing covered
    clinician-administered drugs and related services to covered persons when
   the participating provider obtains clinician-administered drugs from a
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    wholesaler,      a distributor,         an entity,     or   a pharmacy that is    not   a
    participating provider in the insurer's network, if all criteria for
    medical necessity are met;
        (h) Require an enrollee to pay an additional fee, higher copay,
    higher coinsurance, second copay, second coinsurance, or any other form
    of price increase for clinician-administered drugs when not dispensed by
    a pharmacy selected by the insurer; or
       (i)     Require         a specialty pharmacy to     dispense     a clinician-
   administered medication directly to a patient with the intention that the
    patient will transport the medication to a health care provider for
    administration.
        (2)     Notwithstanding section     44-3,131,          any individual or      group
   sickness and accident insurance policy,    certificate,       or subscriber
    contract delivered, issued for delivery, or renewed in this state and any
    hospital,       medical,        or surgical expense-incurred policy,      except for
    policies that provide coverage for a specified disease or other limited-
    benefit coverage, any self-funded employee benefit plan to the extent not
    preempted by federal law, and any pharmacy benefit manager as defined in
    section 44-4603, may offer, but shall not require:
        (a) The use of a home infusion pharmacy to dispense clinician-
    administered drugs to patients in their homes; or
       (b) The use of an infusion site external to a patient's provider
   office or clinic.
        (3) For purposes of this section, clinician-administered drug means
    an outpatient prescription drug other than a vaccine that:
        (a) Cannot reasonably be self-administered to a patient by such
   patient or    by an       individual assisting the patient with the self-
   administration; and
       (b) Is typically administered:
        (i) By a health care provider authorized under the laws of this
    state to administer the drug, including when acting under a physician's
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    delegation and supervision, or by a pharmacist; and
        (ii) In a physician's office, hospital outpatient infusion center,
    pharmacy, or other clinical setting.
       Sec. 2. Section 44-4606, Revised Statutes Cumulative Supplement,
   2024, is amended to read:
       44-4606      (1)   A   participation contract between         a pharmacy benefit
    manager and any pharmacist or    pharmacy providing prescription drug
    coverage for a health benefit plan shall not prohibit or restrict any
   pharmacy or pharmacist from or penalize any pharmacy or pharmacist for
    disclosing to any covered person any health care information that the
    pharmacy or pharmacist deems appropriate regarding:
        (a)   The nature of   treatment,        risks,   or an       alternative to   such
    treatment;
        (b) The availability of an alternate therapy, consultation, or test;
        (c) The decision of a utilization reviewer or similar person to
    authorize or deny a service;
       (d) The process that is used to authorize or deny a health care
   service or benefit; or
        (e) Information on any financial incentive or structure used by the
    health carrier.
        (2) A pharmacy benefit manager shall not prohibit a pharmacy or
    pharmacist from discussing information regarding the total cost for a
    pharmacist service for   a prescription drug or    from selling   a more
   affordable alternative to   the covered person if    a more affordable
   alternative is available.
       (3)   A     pharmacy benefit manager contract with      a participating
   pharmacist or pharmacy shall not prohibit, restrict, or limit disclosure
   of information to the director, law enforcement, or a state or federal
   governmental official, provided that:
        (a) The recipient of the information represents that such recipient
   has the authority, to the extent provided by state or federal law, to
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   maintain proprietary information as confidential; and
        (b) Prior to disclosure of information designated as confidential,
    the pharmacist or pharmacy:
        (i) Marks as confidential any document in which the information
    appears; or
        (ii) Requests confidential treatment for any oral communication of
    the information.
       (4) A pharmacy benefit manager shall not terminate the contract with
   or penalize a pharmacist or pharmacy due to the pharmacist or pharmacy:
        (a)     Disclosing information about     a pharmacy benefit manager
    practice,     except information determined to     be    a trade secret,   as
    determined by state law or the director; or
       (b) Sharing any portion of the pharmacy benefit manager contract
   with the director pursuant to a complaint or a query regarding whether
   the contract is in compliance with the Pharmacy Benefit Manager Licensure
   and Regulation Act.
        (5)(a) A pharmacy benefit manager shall not require a covered person
    purchasing a covered prescription drug to pay an amount greater than the
   lesser of the covered person's cost-sharing amount under the terms of the
    health benefit plan or the amount the covered person would pay for the
    drug if the covered person were paying the cash price.
        (b) Any amount paid by a covered person under subdivision (5)(a) of
    this section shall be attributable toward any deductible or, to the
    extent consistent with section 2707 of the federal Public Health Service
    Act, 42 U.S.C. 300gg-6, as such section existed on January 1, 2022, the
    annual out-of-pocket maximum under the covered person's health benefit
    plan.
        (6)(a)     A   pharmacy benefit manager shall not restrict    a covered
    person's ability to choose how a retail community pharmacy may dispense
    or deliver prescription drugs.
        (b) A pharmacy benefit manager shall not prohibit a retail community
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    pharmacy from shipping, mailing, or any manner of delivering dispensed
    prescription drugs to a covered person at any location requested by the
    covered person if   such shipping,     mailing,   or delivery is    otherwise
    allowed by law.
           (c) A pharmacy benefit manager shall not require a retail community
    pharmacy to participate in a mail-order contract or a contract with terms
    that are substantially similar to a mail-order contract to ship, mail, or
    deliver a prescription drug to a covered person.
           (d) For purposes of this subsection, retail community pharmacy has
    the same meaning as in 42 U.S.C. 1396r-8(k)(10).
           (7) A pharmacy benefit manager shall not violate section 1 of this
    act.
           Sec. 3. Section 44-4610, Revised Statutes Cumulative Supplement,
    2024, is amended to read:
           44-4610 A pharmacy benefit manager shall not exclude a Nebraska
    pharmacy from participation in the pharmacy benefit manager's specialty
    pharmacy network if:
           (1) The pharmacy holds a specialty pharmacy accreditation from a
    nationally recognized independent accrediting organization; and
           (2) The pharmacy is willing to accept reasonable the terms and
    conditions of the pharmacy benefit manager's agreement with the pharmacy
    benefit manager's specialty pharmacies.   Such reasonable terms and
    conditions shall not:
           (a) Exceed reporting requirements and frequency that are required
    for specialty pharmacy accreditation from     a nationally recognized
    independent accrediting organization;
           (b) Exceed performance requirements that are required for specialty
    pharmacy accreditation from    a nationally recognized independent
    accrediting organization; or
           (c) Include excessive or punitive fees.
           Sec. 4.     If any section in this act or any part of any section is
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   declared invalid or unconstitutional, the declaration shall not affect
   the validity or constitutionality of the remaining portions.
       Sec. 5.    Original sections 44-4606 and 44-4610, Revised Statutes
   Cumulative Supplement, 2024, are repealed.
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Statutes affected: 
Introduced: 44-4606, 44-4610