An Act To Address Transparency, Accountability and Oversight of Pharmacy Benefit Managers
Sec. 1. 22 MRSA §1711-E, sub-§1, ¶G, as amended by PL 2011, c. 443, §1, is further amended to read:
Sec. 2. 22 MRSA §1711-E, sub-§1, ¶I, as amended by PL 2007, c. 460, §1, is further amended to read:
Sec. 3. 22 MRSA §8702, sub-§8, as amended by PL 2009, c. 71, §5, is further amended to read:
Sec. 4. 22 MRSA §8702, sub-§8-B, as amended by PL 2011, c. 443, §3, is further amended to read:
Sec. 5. 22 MRSA §8706, sub-§2, ¶C, as amended by PL 2007, c. 136, §5, is further amended to read:
(1) Fees collected pursuant to paragraphs A and B;
(2) Annual assessments of not less than $100 assessed against the following entities licensed under Titles 24 and 24-A: nonprofit hospital and medical service organizations, health insurance carriers and health maintenance organizations on the basis of the total annual health care premium; and 3rd-party administrators, carriers that provide only administrative services for a plan sponsor and pharmacy benefits benefit managers that process and pay claims on the basis of claims processed or paid for each plan sponsor. The assessments are to be determined on an annual basis by the board. Health care policies issued for specified disease, accident, injury, hospital indemnity, disability, long-term care or other limited benefit health insurance policies are not subject to assessment under this subparagraph. For purposes of this subparagraph, policies issued for dental services are not considered to be limited benefit health insurance policies. The total dollar amount of assessments under this subparagraph must equal the assessments under subparagraph (3); and
(3) Annual assessments of not less than $100 assessed by the organization against providers. The assessments are to be determined on an annual basis by the board. The total dollar amount of assessments under this subparagraph must equal the assessments under subparagraph (2).
The aggregate level of annual assessments under subparagraphs (2) and (3) must be an amount sufficient to meet the organization's expenditures authorized in the state budget established under Title 5, chapter 149. The annual assessment may not exceed $1,346,904 in fiscal year 2002-03. In subsequent fiscal years, the annual assessment may increase above $1,346,904 by an amount not to exceed 5% per fiscal year. The board may waive assessments otherwise due under subparagraphs (2) and (3) when a waiver is determined to be in the interests of the organization and the parties to be assessed.
Sec. 6. 24-A MRSA §601, sub-§28, as enacted by PL 2009, c. 581, §3, is amended to read:
Sec. 7. 24-A MRSA §1913, as repealed and replaced by PL 2011, c. 443, §4, is repealed.
Sec. 8. 24-A MRSA §1914 is enacted to read:
§ 1914. Pharmacy benefit managers
An applicant under this section shall pay the registration fee under section 601, subsection 28 upon submission of the application.
(1) The cost of a prescription medication to the covered person; or
(2) The availability of a therapeutically equivalent alternative medication or an alternative method of purchasing the prescription medication, including paying a cash price that is less than the cost of the prescription under the covered person's health benefit plan.
(1) The applicable copayment for the prescription medication;
(2) The allowable claim amount for the prescription medication;
(3) The amount a covered person would pay for the prescription medication without using a health benefit plan or any other source of prescription medication benefits or discounts; and
(4) The amount the pharmacy would be reimbursed for the prescription drug from the pharmacy benefit manager or the insurer for which the pharmacy benefit manager performs services.
A pharmacy benefit manager may designate information required under this subsection as a trade secret as defined in Title 10, section 1542, subsection 4 that may be disclosed only by court order upon a determination of good cause shown. Within 60 days of receipt, the department shall publish a report under this subsection on the department's publicly accessible website in a manner that does not violate Title 10, chapter 302. A pharmacy benefit manager that violates this subsection commits a civil violation for which a penalty of not more than $1,000 per day of violation may be assessed.
Sec. 9. 24-A MRSA §4317, sub-§§4 and 5, as enacted by PL 2011, c. 443, §6, are amended to read:
Sec. 10. 24-A MRSA §4317, sub-§6, as amended by PL 2011, c. 691, Pt. A, §23, is further amended to read:
Sec. 11. 24-A MRSA §4317, sub-§§7 to 9, as enacted by PL 2011, c. 443, §6, are amended to read:
At least 60 days before a pharmacy or pharmacist terminates its participation in a pharmacy benefits benefit manager's plan or network, the pharmacy or pharmacist shall give the pharmacy benefits benefit manager a written explanation of the reason for the termination.
Sec. 12. 24-A MRSA §4317, sub-§10, as amended by PL 2013, c. 71, §1, is further amended to read:
Sec. 13. 24-A MRSA §4317, sub-§11, as enacted by PL 2011, c. 443, §6, is amended to read:
Sec. 14. 24-A MRSA §4317, sub-§12, as enacted by PL 2015, c. 450, §1, is amended to read:
(1) Is rated as "A" or "B" in the most recent version of the United States Food and Drug Administration's "Approved Drug Products with Therapeutic Equivalence Evaluations," also known as "the Orange Book," or an equivalent rating from a successor publication, or is rated as "NR" or "NA" or a similar rating by a nationally recognized pricing reference; and
(2) Is not obsolete and is generally available for purchase in this State from a national or regional wholesale distributor by pharmacies having a contract with the pharmacy benefits benefit manager.
(1) Upon request, disclose the sources used to establish the maximum allowable costs used by the pharmacy benefits benefit manager;
(2) Provide a process for a pharmacy to readily obtain the maximum allowable reimbursement available to that pharmacy under a maximum allowable cost list; and
(3) At least once every 7 business days, review and update maximum allowable cost list information to reflect any modification of the maximum allowable reimbursement available to a pharmacy under a maximum allowable cost list used by the pharmacy benefits benefit manager.
(1) If the appeal is upheld, the pharmacy benefits benefit manager shall make the appropriate adjustment in the maximum allowable cost and permit the challenging pharmacy or pharmacist to reverse and rebill the claim in question; or
(2) If the appeal is denied, the pharmacy benefits benefit manager shall provide the challenging pharmacy or pharmacist the national drug code from national or regional wholesalers of a comparable prescription drug that may be purchased at or below the maximum allowable cost.
Sec. 15. 24-A MRSA §4317, sub-§13, as enacted by PL 2017, c. 44, §1, is amended to read:
This bill requires that pharmacy benefit managers, which are entities that manage an insurer's prescription drug coverage, be registered by the Department of Health and Human Services. It sets standards for registration including:
1. Allowing the department to revoke, suspend or place on probation a pharmacy benefit manager's registration for fraudulent activities, to protect the safety and interest of a consumer or if the pharmacy benefit manager violates state law;
2. Setting out required pharmacy benefit manager business practices, including:
3. Requiring an annual report from a pharmacy benefit manager that details the rebates received by the pharmacy benefit manager from pharmaceutical manufacturers for use of the manufacturers' prescription drugs and the disposition of those rebates.