Cost-sharing cap on insulin
This bill prohibits every health insurance policy and governmental self-insured health plan that cover insulin and impose cost sharing on prescription drugs from imposing cost sharing on insulin in an amount that exceeds $35 for a one-month supply. Current law requires every health insurance policy that provides
coverage of expenses incurred for treatment of diabetes to provide coverage for specified expenses and items, including insulin. The required coverage under
current law for certain diabetes treatments other than insulin infusion pumps is subject to the same exclusions, limitations, deductibles, and coinsurance provisions
of the policy as other covered expenses. The bill’s cost-sharing limitation on insulin supersedes the specification that the exclusions, limitations, deductibles, and
coinsurance are the same as for other coverage.
Fiduciary and disclosure requirements for pharmacy benefit managers
The bill imposes fiduciary and disclosure requirements on pharmacy benefit
managers. Pharmacy benefit managers contract with health plans that provide
prescription drug benefits to administer those benefits for the plans. They also have
contracts with pharmacies and pay the pharmacies for providing the drugs to the
plan beneficiaries.
The bill provides that a pharmacy benefit manager owes a fiduciary duty to a
plan sponsor. The bill also requires that a pharmacy benefit manager annually
disclose all of the following information to the plan sponsor:
1. The indirect profit received by the pharmacy benefit manager from owning
a pharmacy or service provider.
2. Any payments made to a consultant or broker who works on behalf of the plan
sponsor.
3. From the amounts received from drug manufacturers, the amounts retained
by the pharmacy benefit manager that are related to the plan sponsor’s claims or
bona fide service fees.
4. The amounts received from network pharmacies and the amount retained
by the pharmacy benefit manager.
Reimbursements for certain 340B program entities
The bill prohibits any person from reimbursing certain entities that participate
in the federal drug pricing program, known as the 340B program, for a drug subject
to an agreement under the program at a rate lower than that paid for the same drug
to pharmacies that have a similar prescription volume. The bill also prohibits a
person from imposing any fee, charge back, or other adjustment on the basis of the
entity’s participation in the 340B program. The entities covered by the prohibitions
under the bill are federally qualified health centers, critical access hospitals, and
grantees under the federal Ryan White HIV/AIDS program, as well as these entities’
pharmacies and any pharmacy with which any of the entities have contracted to
dispense drugs through the 340B program.