2022- 2023 Arizona Legislative Session
Sponsor: Senator Nancy Barto
Prescription Drug Coverage Steering Prohibition
Prohibits a pharmacy benefit manager from steering or directing a patient to use the manager's affiliated pharmacy or durable medical equipment provider.
Why it Matters:
Stops pharmacy benefit managers from requiring a patient to use the PBM's affiliated provider in order for that patient to receive the maximum benefit under their health benefit's plan
Prohibits pharmacy benefit managers from transferring records containing patient or prescriber identifiable prescription information to or from an affiliated provider for a commercial purpose;
Stops pharmacy benefit managers, health insurers, or third-party payors from requiring a clinician-administered drug to be dispensed by a pharmacy as a condition of coverage;
Prohibits pharmacy benefit managers, health insurers, or third-party payors from covering prescription drugs as a different benefit with cost-sharing requirements that impose greater expense on the patient, if the drug is dispensed or administered at the prescriber's office, a hospital outpatient infusion center, or any other outpatient clinical setting.
Blocked by the Opposition
Sponsors: Senator Boyer, Representative Cobb
Strike Everything Amendment: Pharmacy benefits managers, steering prohibition
Prohibits a pharmacy benefit manager (PBM) from steering or directing a patient to use the manager's affiliated pharmacy.
1. Prohibits a PBM from transferring to or receiving from its affiliated provider a record containing patient or prescriber identifiable prescription information for a commercial purpose. (Sec. 1)
2. Asserts that commercial purposes do not include pharmacy reimbursemengt, formulary compliance, pharmaceutical care, utilization review by a health care provider or a public health activity authorized by law. (Sec. 1)
3. Forbids a PBM from steering or directing a patient to use their affiliated provider. (Sec. 1)
4. Asserts that the prohibition on steering a patient to an affiliated provider does not bar a PBM from including its affiliated provider in any communications with a patient or prospective patient if the communication is both:
a) Regarding information about the cost or services provided by pharmacies or durable medical equipment providers in the network of a health benefits plan in which the patient or prospective patient is enrolled; and
b) Includes accurate comparable information regarding pharmacies or durable medical equipment providers in the network that are not the issuer's or PBM's affiliated providers. (Sec. 1)
5. Forbids PBM's from: a) Requiring a patient to use the PBM's affiliated provider for the patient to receive the maximum benefit under their health benefit's plan; b) Requiring or inducing a patient to use the PBM's affiliated provider, including by providing reduced cost sharing if the patient uses the affiliated provider; c) Soliciting a patient or prescriber to transfer a patient's prescription to the PBM's affiliated provider; and d) Requiring a pharmacy or durable medical equipment provider that is not an affiliated provider to transfer a patient's prescription to the PMS's affiliated provider without written consent of the patient. (Sec. 1)
6. Specifies that this does not prohibit a patient from personally requesting to transfer the patient's prescription without written consent. (Sec. 1)
7. Applies the prohibitions relating to steering or requiring a patient to use an affiliated provider to a PBM acting on its own behalf or on the behalf of an insurer. (Sec. 1)
8. Prohibits a PBM or health insurer from: a) Requiring a clinician-administered drug to be dispensed by a pharmacy, including by an affiliated provider, as a condition of coverage; b) Limiting or excluding coverage of a clinician-administered drug or prescription drug that is not dispensed by a pharmacy or affiliated provider, if the prescription drug is covered under the health benefits plan or pharmacy benefit plan; and c) Covering a prescription drug as a different benefit or tier or with cost sharing requirements that impose greater expense for a covered individual if the drug is dispensed or administered at the prescriber's office, a hospital outpatient infusion center or any other outpatient clinical setting rather than a pharmacy or affiliated provider. (Sec. 1)
9. Clarifies that the restrictions relating to clinician-administered drugs does not authorize a person to administer prescription drugs that are otherwise prohibited under state and federal law or modify prescription drug administration requirements under state law, including any requirements related to delegating and supervising prescription drug administration. (Sec. 1)
10. Specifies these provisions do not apply to health and accident insurance coverage procured by the Department of Administration or by the Arizona State Retirement System. (Sec. 1)
11. Defines terms. (Sec. 1)
12. Applies the requirements and prohibitions of this legislation to contracts entered into, amended, extended or renewed on or after the effective date. (Sec. 2)
13. Contains a severability clause. (Sec. 3)
Blocked by the Opposition
Signed by the Governor
2021-2022 Arizona Legislative Session
Sponsor: Senator Nancy Barto
End PBM Transaction Fees
This bill amends Chapter 25, Article 2 of the Insurance Code by adding Section 20-3332 to prohibit PBMs operating in Arizona from holding a pharmacist or pharmacy responsible for a fee for any step or component of, or mechanism related to, the adjudication of a claim, including:
Adjudicating a pharmacy benefit claim;
Processing or transmitting a pharmacy benefit claim;
Developing or managing a claim processing or adjudication network; or
Participating in a claim processing or claim adjudication network.
The bill also allows a pharmacy to file a complaint with the AZ Dept. of Insurance (ADI) for a violation of Sec. 20-3332 and would grant ADI authority to seek injunctive relief to halt transaction fees or to impose penalties on, or bring legal action against, a PBM for assessing the fees.
Why it's important:
Ends unfair, unjustified charges that cannot be realistically explained as anything other than a PBM practice to generate revenue at pharmacies’ expense;
Establishes equity among Arizona health-care providers in how they are treated when submitting health-care claims for adjudication;
Strengthens the financial viability of Arizona pharmacies, which play a critical role during the pandemic in providing medications, vaccinations and other vital services to Arizonans.