2024 24LSO-0025
STATE OF WYOMING Working Draft
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DRAFT ONLY
NOT APPROVED FOR
INTRODUCTION
HOUSE BILL NO.
Physician-administered medication regulations.
Sponsored by: Joint Labor, Health & Social Services Interim Committee
A BILL
for
1 AN ACT relating to the insurance code; prohibiting adverse
2 insurance-related actions covering physician-administered
3 medication; providing definitions; providing requirements
4 related to physician-administered medication; providing
5 remedies for violations of this act; making a conforming
6 amendment; requiring rulemaking; and providing for
7 effective dates.
8
9 Be It Enacted by the Legislature of the State of Wyoming:
10
11 Section 1. W.S. 26-55-101 through 26-55-103 are
12 created to read:
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1
2 CHAPTER 55 – PHYSICIAN-ADMINISTERED MEDICATION
3
4 26-55-101. Purpose.
5
6 The purpose of this chapter is to ensure patient access to
7 physician-administered drugs and related services furnished
8 to persons covered under a health insurance plan. This
9 chapter shall ensure that health insurance issuers do not
10 interfere with patients' freedom of choice with respect to
11 providers furnishing physician-administered drugs and
12 ensure that patients receive safe and effective drug
13 therapies.
14
15 26-55-102. Definitions.
16
17 (a) As used in this chapter:
18
19 (i) "Covered person" means a policyholder,
20 subscriber, enrollee, insured or other individual enrolled
21 in a health insurance plan as defined by W.S. 9-3-
22 203(a)(vi) and who is receiving health care services from a
23 participating provider pursuant to the participating
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1 provider's contract or agreement with a health insurance
2 issuer;
3
4 (ii) "Health insurance issuer" means as defined
5 by W.S. 26-20-801(a)(ii);
6
7 (iii) "Health insurance plan" means a policy,
8 contract, certificate or subscriber agreement entered into,
9 offered or issued by a health insurance issuer to provide,
10 deliver, arrange for, pay for or reimburse any of the costs
11 of health care services. "Health insurance plan" does not
12 include Medicaid or Medicare plans;
13
14 (iv) "Medical necessity" means as defined by
15 W.S. 26-40-102(a)(iii);
16
17 (v) "Participating provider" means a health care
18 provider who, under a contract or agreement with a health
19 insurance issuer or with the health insurance issuer's
20 contractor or subcontractor, has agreed to provide health
21 care services to covered persons with an expectation of
22 receiving payment, other than in-network coinsurance,
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1 copayments or deductibles, directly or indirectly from the
2 health insurance issuer;
3
4 (vi) "Physician-administered drug" means any
5 prescription drug other than a vaccine that requires
6 administration by a participating provider and is not
7 approved as a self-administered drug;
8
9 (vii) "Pharmacy" means as defined by W.S. 26-52-
10 102(a)(vi);
11
12 (viii) "Pharmacy benefit manager" means as
13 defined by W.S. 26-52-102(a)(vii).
14
15 26-55-103. Prohibited actions by health insurance
16 issuers and pharmacy benefit managers; requirements;
17 exceptions; violators subject to the Unfair Trade
18 Practices Act.
19
20 (a) A health insurance issuer, pharmacy benefit
21 manager or person acting on behalf of a pharmacy benefit
22 manager shall not:
23
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1 (i) Refuse to authorize, approve or pay a
2 participating provider for providing covered physician-
3 administered drugs and related services to covered persons;
4
5 (ii) Condition, deny, restrict, refuse to
6 authorize or reduce payment to a participating provider for
7 a physician-administered drug when administration of the
8 drug is a medical necessity and the participating provider
9 obtains the physician-administered drug from a pharmacy
10 that is not a participating provider in the health
11 insurance issuer's network.
12
13 (b) Subsection (a) of this section shall apply only
14 to a physician-administered drug that meets the supply
15 chain security controls and chain of distribution set by
16 the Drug Supply Chain Security Act, Pub. L. 113-54, as
17 amended. All payments for a physician-administered drug
18 required by subsection (a) of this section shall be at a
19 rate set forth in the health insurance issuer's agreement
20 with the participating provider and, if no rate is
21 established in the agreement, at the wholesale acquisition
22 cost.
23
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1 (c) A health insurance issuer, pharmacy benefit
2 manager or person acting on behalf of a pharmacy benefit
3 manager shall not require a covered person to pay an
4 additional fee, or any other increased cost-sharing amount,
5 in addition to cost-sharing amounts payable by the covered
6 person as required within the health benefit plan, to
7 obtain the physician-administered drug when provided by a
8 participating provider. Nothing in this chapter shall
9 prohibit a health insurance issuer or its agent from
10 establishing differing copayments or other cost-sharing
11 amounts within the health insurance plan for covered
12 persons who acquire physician-administered drugs from other
13 providers.
14
15 (d) Nothing in this chapter shall prohibit a health
16 insurance issuer or its agent from refusing to authorize or
17 approve, or from denying coverage for a physician-
18 administered drug based upon a failure to satisfy medical
19 necessity criteria. For purposes of this section, the
20 location of receiving the physician-administered drug shall
21 not be included in the medical necessity criteria.
22
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1 (e) The commission of any act prohibited by this
2 chapter shall be considered an unfair method of competition
3 and an unfair practice or act which shall subject the
4 violator to any and all actions provided for in the Unfair
5 Trade Practices Act under W.S. 26-13-101 through 26-13-125.
6
7 (f) Any provision of a contract that is contrary to
8 any provision of this chapter shall be void and
9 unenforceable in this state.
10
11 Section 2. W.S. 26-13-102 is amended to read:
12
13 26-13-102. Unfair methods and deceptive acts
14 prohibited.
15
16 No person shall engage in this state in any trade practice
17 prohibited by W.S. 26-55-101 through 26-55-103 or which is
18 defined in this article as or is determined pursuant to
19 this article to be an unfair method of competition or an
20 unfair or deceptive act or practice in the business of
21 insurance.
22
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1 Section 3. The department of insurance shall
2 promulgate any rules necessary to implement this act.
3
4 Section 4.
5
6 (a) Except as otherwise provided by subsection (b) of
7 this section, this act is effective July 1, 2024.
8
9 (b) Sections 3 and 4 of this act are effective
10 immediately upon completion of all acts necessary for a
11 bill to become law as provided by Article 4, Section 8 of
12 the Wyoming Constitution.
13
14 (END)
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Statutes affected:
24LSO-0025 v0.5: 26-13-102