Bill Summary – FastDemocracy

LEGISLATIVE GENERAL COUNSEL                                             S.B. 184
Approved for Filing: C. Williams 6                            1st Sub. (Green)
          6 02-09-23 7:17 PM 6
                         Senator Curtis S. Bramble proposes the following substitute bill:
                           PRESCRIPTION COST AMENDMENTS
                                       2023 GENERAL SESSION
                                            STATE OF UTAH
                                Chief Sponsor: Curtis S. Bramble
                                House Sponsor: Karianne Lisonbee
 6
 LONG TITLE
 General Description:
        This bill enacts provisions related to health benefit plan cost sharing.
 Highlighted Provisions:
        This bill:
        < defines terms;
        < requires an insurer to calculate any amounts paid on behalf of an individual towards
 the individual's cost sharing requirement;
        < requires a pharmacy benefit manager to calculate any amounts paid on behalf of an
 individual towards the individual's cost sharing requirement; and
        < makes technical changes.
 Money Appropriated in this Bill:
        None
 Other Special Clauses:                                                                          1st Sub. S.B. 184
        None
 Utah Code Sections Affected:
 AMENDS:
        31A-46-102, as last amended by Laws of Utah 2020, Chapters 198, 275 and 372
 ENACTS:
     *SB0184S01*
        1st Sub. (Green) S.B. 184                                                    02-09-23 7:17 PM
          31A-46-311, Utah Code Annotated 1953
  REPEALS AND REENACTS:
          31A-22-657, as enacted by Laws of Utah 2022, Chapter 198
29
  Be it enacted by the Legislature of the state of Utah:
          Section 1. Section 31A-22-657 is repealed and reenacted to read:
          31A-22-657. Cost sharing requirements for health benefit plans.
          (1) As used in this section:
          (a) (i) "Cost sharing requirement" means any copayment, coinsurance, deductible, or
  annual limitation on cost sharing required by a health benefit plan for a specific health care
  service covered by the health benefit plan.
          (ii) "Cost sharing requirement" includes any copayment, coinsurance, deductible, or
  annual limitation that is subject to 42 U.S.C. Secs. 18022(c) or 300gg-6(b).
          (b) (i) "Health care service" means an item or service furnished to an individual for the
  purpose of preventing, alleviating, curing, or healing human illness, injury, or physical
  disability.
          (ii) "Health care service" includes a prescription drug.
          (c) "High deductible health plan" means the same as that term is defined in 26 U.S.C.
  Sec. 223(c)(2).
          (d) "Insurer" means the same as that term is defined in Section
45a   Öº [31A-22-636] 31A-1-301 »Ö .
          (2) When calculating an enrollee's contribution to any applicable cost sharing
  requirement for a health care service, an insurer shall include any cost sharing amounts paid:
          (a) by the enrollee; or
          (b) on behalf of the enrollee by another person.
          (3) (a) Except as provided in Subsection (3)(b), an insurer shall calculate cost sharing
  requirements for a health care service in accordance with Subsection (2) even if the enrollee
  has not met the enrollee's deductible.
          (b) An insurer may calculate cost sharing requirements for a health care service in
  accordance with Subsection (2) after the enrollee has met the enrollee's minimum deductible
  under 26 U.S.C. Sec. 223 only if:
          (i) the enrollee is enrolled in a health benefit plan that is a high deductible health plan;
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       02-09-23 7:17 PM                                                 1st Sub. (Green) S.B. 184
        (ii) calculating the cost sharing requirements in accordance with Subsection (2) before
 the enrollee has met the high deductible health plan's minimum deductible under 26 U.S.C.
 Sec. 223 would result in health savings account ineligibility under 26 U.S.C. Sec. 223; and
        (iii) the health care service is not preventive care under 26 U.S.C. Sec. 223(c)(2)(C).
        (4) This section applies to any health benefit plan entered into, amended, extended, or
 renewed on or after January 1, 2024.
        (5) The commissioner may make rules in accordance with Title 63G, Chapter 3, Utah
 Administrative Rulemaking Act, to implement this section.
        Section 2. Section 31A-46-102 is amended to read:
        31A-46-102. Definitions.
        As used in this chapter:
        (1) "340B drug" means a drug purchased through the 340B drug discount program by a
 340B entity.
        (2) "340B drug discount program" means the 340B drug discount program described in
 42 U.S.C. Sec. 256b.
        (3) "340B entity" means:
        (a) an entity participating in the 340B drug discount program;
        (b) a pharmacy of an entity participating in the 340B drug discount program; or
        (c) a pharmacy contracting with an entity participating in the 340B drug discount
 program to dispense drugs purchased through the 340B drug discount program.
        (4) "Administrative fee" means any payment, other than a rebate, that a pharmaceutical
 manufacturer makes directly or indirectly to a pharmacy benefit manager.
        (5) "Allowable claim amount" means the amount paid by an insurer under the
 [customer's] enrollee's health benefit plan.
        (6) "Contracting insurer" means an insurer with whom a pharmacy benefit manager
 contracts to provide a pharmacy benefit management service.
        (7) "Cost share" means the amount paid by an [insured customer under the customer's]
 enrollee under the enrollee's health benefit plan.
        (8) "Cost sharing requirement" means the same as that term is defined in Section
 31A-22-657.
        [(8)] (9) "Device" means the same as that term is defined in Section 58-17b-102.
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       1st Sub. (Green) S.B. 184                                                 02-09-23 7:17 PM
        [(9)] (10) "Direct or indirect remuneration" means any adjustment in the total
 compensation:
        (a) received by a pharmacy from a pharmacy benefit manager for the sale of a drug,
 device, or other product or service; and
        (b) that is determined after the sale of the product or service.
        [(10)] (11) "Dispense" means the same as that term is defined in Section 58-17b-102.
        [(11)] (12) "Drug" means the same as that term is defined in Section 58-17b-102.
        (13) "Health care service" means the same as that term is defined in Section
 31A-22-657.
        (14) "High deductible health plan" means the same as that term is defined in 26 U.S.C.
 Sec. 223(c)(2).
        [(12)] (15) "Insurer" means the same as that term is defined in Section 31A-22-636.
        [(13)] (16) "Maximum allowable cost" means:
        (a) a maximum reimbursement amount for a group of pharmaceutically and
 therapeutically equivalent drugs; or
        (b) any similar reimbursement amount that is used by a pharmacy benefit manager to
 reimburse pharmacies for multiple source drugs.
        [(14)] (17) "Medicaid program" means the same as that term is defined in Section
 26-18-2.
        [(15)] (18) "Obsolete" means a product that may be listed in national drug pricing
 compendia but is no longer available to be dispensed based on the expiration date of the last lot
 manufactured.
        [(16)] (19) "Patient counseling" means the same as that term is defined in Section
 58-17b-102.
        [(17)] (20) "Pharmaceutical facility" means the same as that term is defined in Section
 58-17b-102.
        [(18)] (21) "Pharmaceutical manufacturer" means a pharmaceutical facility that
 manufactures prescription drugs.
        [(19)] (22) "Pharmacist" means the same as that term is defined in Section 58-17b-102.
        [(20)] (23) "Pharmacy" means the same as that term is defined in Section 58-17b-102.
        [(21)] (24) "Pharmacy benefits management service" means any of the following
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        02-09-23 7:17 PM                                                    1st Sub. (Green) S.B. 184
 services provided to a health benefit plan, or to a participant of a health benefit plan:
         (a) negotiating the amount to be paid by a health benefit plan for a prescription drug; or
         (b) administering or managing a prescription drug benefit provided by the health
 benefit plan for the benefit of a participant of the health benefit plan, including administering
 or managing:
         (i) an out-of-state mail service pharmacy;
         (ii) a specialty pharmacy;
         (iii) claims processing;
         (iv) payment of a claim;
         (v) retail network management;
         (vi) clinical formulary development;
         (vii) clinical formulary management services;
         (viii) rebate contracting;
         (ix) rebate administration;
         (x) a participant compliance program;
         (xi) a therapeutic intervention program;
         (xii) a disease management program; or
         (xiii) a service that is similar to, or related to, a service described in Subsection [(21)(a)
 or (21)(b)(i)] (24)(a) or (24)(b)(i) through (xii).
         [(22)] (25) "Pharmacy benefit manager" means a person licensed under this chapter to
 provide a pharmacy benefits management service.
         [(23)] (26) "Pharmacy service" means a product, good, or service provided to an
 individual by a pharmacy or pharmacist.
         [(24)] (27) "Pharmacy services administration organization" means an entity that
 contracts with a pharmacy to assist with third-party payer interactions and administrative
 services related to third-party payer interactions, including:
         (a) contracting with a pharmacy benefit manager on behalf of the pharmacy; and
         (b) managing a pharmacy's claims payments from third-party payers.
         [(25)] (28) "Pharmacy service entity" means:
         (a) a pharmacy services administration organization; or
         (b) a pharmacy benefit manager.
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        1st Sub. (Green) S.B. 184                                                 02-09-23 7:17 PM
         [(26)] (29) "Prescription device" means the same as that term is defined in Section
 58-17b-102.
         [(27)] (30) "Prescription drug" means the same as that term is defined in Section
 58-17b-102.
         [(28)] (31) (a) "Rebate" means a refund, discount, or other price concession that is paid
 by a pharmaceutical manufacturer to a pharmacy benefit manager based on a prescription
 drug's utilization or effectiveness.
         (b) "Rebate" does not include an administrative fee.
         [(29)] (32) (a) "Reimbursement report" means a report on the adjustment in total
 compensation for a claim.
         (b) "Reimbursement report" does not include a report on adjustments made pursuant to
 a pharmacy audit or reprocessing.
         [(30)] (33) "Retail pharmacy" means the same as that term is defined in Section
 58-17b-102.
         [(31)] (34) "Sale" means a prescription drug or prescription device claim covered by a
 health benefit plan.
         [(32)] (35) "Wholesale acquisition cost" means the same as that term is defined in 42
 U.S.C. Sec. 1395w-3a.
         Section 3. Section 31A-46-311 is enacted to read:
         31A-46-311. Cost sharing requirements for pharmacy benefit managers.
         (1) When calculating an enrollee's contribution to any applicable cost sharing
 requirement for a health care service, a pharmacy benefit manager shall include any cost
 sharing amounts paid:
         (a) by the enrollee; or
         (b) on behalf of the enrollee by another person.
         (2) (a) Except as provided in Subsection (2)(b), a pharmacy benefit manager shall
 calculate cost sharing requirements for a health care service in accordance with Subsection (1)
 even if the enrollee has not met the enrollee's minimum deductible.
         (b) A pharmacy benefit manger may calculate cost sharing requirements for a health
 care service in accordance with Subsection (1) after the enrollee has met the minimum
 deductible under 26 U.S.C. Sec. 223 only if:
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       02-09-23 7:17 PM                                                    1st Sub. (Green) S.B. 184
        (i) the enrollee is enrolled in a health benefit plan that is a high deductible health plan;
        (ii) calculating the cost sharing requirements in accordance with Subsection (1) before
 the enrollee has met the high deductible health plan's minimum deductible would result in
 health savings account ineligibility under 26 U.S.C. Sec. 223; and
        (iii) the health care service is not preventive care under 26 U.S.C. Sec. 223(c)(2)(C).
        (3) This section applies to any health benefit plan entered into, amended, extended, or
 renewed on or after January 1, 2024.
        (4) The commissioner may make rules in accordance with Title 63G, Chapter 3, Utah
 Administrative Rulemaking Act, to implement this section.
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Statutes affected: 
Introduced: 31A-22-657, 31A-46-102
Amended: 31A-22-657, 31A-46-102