PRINTER'S NO. 871
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No. 882
Session of
2021
INTRODUCED BY GAYDOS, POLINCHOCK, HILL-EVANS, JAMES, SAYLOR,
MOUL, ZIMMERMAN, HERSHEY, CIRESI, MILLARD AND THOMAS,
MARCH 12, 2021
REFERRED TO COMMITTEE ON INSURANCE, MARCH 12, 2021
AN ACT
1 Amending the act of November 21, 2016 (P.L.1318, No.169),
2 entitled "An act providing for pharmacy audit procedures, for
3 registration of pharmacy benefits managers and auditing
4 entities, for maximum allowable cost transparency and for
5 prescription drugs reimbursed under the PACE and PACENET
6 program; and making related repeals," in pharmacy benefit
7 manager cost transparency requirements, providing for sharing
8 of cost, benefit and coverage data required.
9 The General Assembly of the Commonwealth of Pennsylvania
10 hereby enacts as follows:
11 Section 1. The act of November 21, 2016 (P.L.1318, No.169),
12 known as the Pharmacy Audit Integrity and Transparency Act, is
13 amended by adding a section to read:
14 Section 703.1. Sharing of cost, benefit and coverage data
15 required.
16 (a) General rule.--A health insurer or PBM shall, upon
17 request of a covered individual, the covered individual's health
18 care practitioner or a third party on behalf of the covered
19 individual or health care practitioner, furnish the cost,
20 benefit and coverage data specified in subsection (d) to the
 1 covered individual, the health care practitioner or the third
2 party and shall ensure that such data is:
3 (1) Current no later than one business day after any
4 change is made.
5 (2) Provided in real time.
6 (3) In the same format that the request is made by the
7 covered individual, the health care practitioner or the third
8 party.
9 (b) Format of request.--The request must be submitted with
10 established industry content and transport standards published
11 by:
12 (1) a standards developing organization accredited by
13 the American National Standards Institute, including the
14 National Council for Prescription Drug Programs, ASC X12,
15 Health Level 7; or
16 (2) a relevant Federal or State governing body,
17 including the Centers for Medicare and Medicaid Services or
18 the Office of the National Coordinator for Health Information
19 Technology.
20 (c) Electronic formats unacceptable.--A facsimile,
21 proprietary payor or patient portal or other electronic form
22 shall not be considered an acceptable electronic format under
23 this section.
24 (d) Required data.--Upon request, the following data shall
25 be provided for a drug covered under the covered individual's
26 health policy:
27 (1) The covered individual's eligibility information for
28 the drug.
29 (2) A list of clinically-appropriate alternatives to the
30 drug covered under the covered individual's health plan.
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 1 (3) Cost-sharing information for the drug and
2 alternatives, including a description of a variance in cost-
3 sharing based on pharmacy, whether retail or mail order, or
4 health care provider dispensing or administering the drug or
5 alternative.
6 (4) The applicable utilization management requirements
7 for the drug or alternatives, including prior authorization,
8 step therapy, quantity limits and site-of-service
9 restrictions.
10 (e) Duty to provide information.--A health insurer or PBM
11 shall furnish the data specified in subsection (d), whether the
12 request is made using the drug's unique billing code, such as a
13 National Drug Code or Healthcare Common Procedure Coding System
14 code, or descriptive term, such as the brand or generic name of
15 the drug.
16 (f) Prohibited conduct.--
17 (1) A health insurer or PBM may not deny or delay a
18 request as a method of blocking the data specified in
19 subsection (d) from being shared based on how the drug was
20 requested.
21 (2) A health insurer or PBM furnishing the data
22 specified in subsection (d) may not:
23 (i) Restrict, prohibit or otherwise hinder a health
24 care professional or health care provider from
25 communicating or sharing the data specified in subsection
26 (d) or additional information on a lower-cost or
27 clinically appropriate alternative, whether or not
28 covered under the covered individual's plan or additional
29 payment or cost-sharing information that may reduce the
30 patient's out-of-pocket costs, such as cash price or
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 1 patient assistance and support programs whether sponsored
2 by a manufacturer, foundation or other entity.
3 (ii) Except as may be required by law, interfere
4 with, prevent or materially discourage access to,
5 exchange or use of the data specified in subsection (d),
6 including charging fees, not responding to a request at
7 the time made where a response is reasonably possible,
8 implementing technology in nonstandard ways or
9 instituting covered individual consent requirements,
10 processes, policies, procedures or renewals that are
11 likely to substantially increase the complexity or burden
12 of accessing, exchanging or using the data.
13 (iii) Penalize a health care practitioner for
14 disclosing the data specified in subsection (d) to a
15 covered individual or prescribing, administering or
16 ordering a clinically appropriate or lower-cost
17 alternative.
18 (g) Personal representatives.--
19 (1) For the purposes of this section, a health insurer
20 or PBM shall treat a personal representative as the covered
21 individual.
22 (2) If, under applicable law, a person has authority to
23 act on behalf of a covered individual in making decisions
24 relating to health care, a health insurer or PBM or an
25 affiliate or entity acting on its behalf, shall treat the
26 person as a personal representative under this section.
27 Section 2. This act shall take effect in 60 days.
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