SB 918 - This act establishes provisions relating to pharmacy benefits and pharmacy benefit managers (PBMs).
PHARMACY BENEFIT AND PHARMACY BENEFIT MANAGERS
This act prohibits pharmacy benefit managers from automatically enrolling a pharmacy in a contract, modifying an existing contract without affirmation from the pharmacy, or requiring a pharmacy or pharmacist to participate in one PBM contract in order to participate in another contract. Nor shall a PBM discriminate between in-network pharmacies or pharmacists on the basis of copayments or days of supply unless such pharmacy declines to fill such prescriptions at the price allowed to other in-network pharmacies for such prescription.
A PBM is also prohibited from reassigning a prescription that has been presented in one pharmacy to another pharmacy in the PBM's network. When the PBM contacts the prescribing health care practitioner to affirm or modify the original prescription, the affirmed or modified prescription shall be filled at the in-network pharmacy of the patient's choice to which the insured presented the original prescription. This provision is not applicable to any prescribed specialty drug with a specific formulation. SECTION 376.388
This act establishes procedures for governing switch communications. A switch communication is defined as a communication from a health insurance carrier or PBM to a patient or the patient's physician that recommends a patient's medication be switched by the original prescribing practitioner to a different medication than the medication originally prescribed.
The switch communication shall, among other requirements, explain any financial incentives that may be provided to, or have been offered to, the prescribing practitioner by the health carrier or PBM that could result in the switch to the different drug. In addition, the communication shall explain any clinical effects that the proposed medication may have on the patient which are different than those of the originally prescribed medication. The patient shall also be informed of any cost sharing changes for which the patient shall be responsible and advise the patient of his or her rights to discuss any proposed switch with the patient's prescribing practitioner.
Any time a patient's medication is recommended to be switched to a medication other than that originally prescribed by the prescribing practitioner, a switch communication shall be sent to the patient. Also, information shall be sent to the plan sponsor or health carrier using a PBM regarding, among other information, the recommended medication and the cost, shown in currency form, of the originally prescribed medication. These provisions do not apply to generic substitutions allowed under current law in Section 338.056, RSMo, unless such substitution results in a higher cost to the patient or health insurance payer.
All health carriers and PBMs shall submit the format and language to the Department of Insurance, Financial Institutions, and Professional Registration for approval. The department shall have sixty days to review and inform the health carrier or PBM that the format and language of the switch communication either does or does not comply with the statute. If the department finds noncompliance with the statute, the department shall cite specific reasons for such decision.
The department shall promulgate rules governing switch communications. Such rules shall include procedures for verifying the accuracy of any switch communications from health carriers and PBMs to ensure that such switch communications are truthful, accurate, and not misleading. Also, except for a substitution due to the Food and Drug Administration's withdrawal of a drug for prescription, such rules shall include a requirement that all switch communications bear a prominent notification on a first page clearly indicating the switch communication is not a product safety notice.
This act also specifies that a PBM owes a fiduciary duty to a covered entity and shall discharge that duty in accordance with the provisions of state and federal law. A PBM shall notify the covered entity in writing of any activity, policy, or practice of the PBM that directly or indirectly presents any conflict of interest with the duties imposed by this act. SECTIONS 376.1460 and 376.1462
PHYSICIAN OVERRIDE OF MEDICATION RESTRICTIONS
This act governs the practice by health carriers and pharmacy benefit managers of restricting medications for the treatment of any medical condition by requiring step therapy or a fail first protocol. A prescribing practitioner may override such restrictions if the prescriber can demonstrate, based on sound clinical evidence, that the step therapy or fail first protocol treatment has been ineffective in treating the patient's disease or medical condition, is expected to be ineffective, or is likely to cause an adverse reaction. The duration of any step therapy or fail first protocol cannot last longer than 14 days when such treatment is deemed clinically ineffective by the prescribing physician. However, when the health carrier or PBM can show, through sound clinical evidence, the originally prescribed medication is likely to require more than two weeks to provide any relief to the patient, the step therapy or fail first protocol may be extended up to seven additional days.
Nothing in the act shall require coverage for a condition specifically excluded by the policy which is not otherwise mandated by law. SECTION 376.1464