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BILL AS INTRODUCED 2007-2008

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S.87

Introduced by Senator Cummings of Washington County and Senator MacDonald of Orange District

Referred to Committee on

Date:

Subject:  Health; insurance; pharmacy benefits

Statement of purpose:  This bill proposes to: (1) require health insurers and pharmacy benefit managers to give notice to consumers that the consumer can obtain a prescription from a community retail pharmacy for the same

co-payment as from a mail-order pharmacy; (2) prohibit an insurer or pharmacy benefit manager from telling a customer that a community retail pharmacy may be unwilling or unable to fill the prescription with the same co-pay; and (3) make a violation of these provisions a violation of the Consumer Fraud Act.

AN ACT RELATING TO GIVING CONSUMERS NOTICE OF THE RIGHT TO BUY PRESCRIPTIONS FROM RETAIL PHARMACIES FOR THE SAME CO-PAY AS FROM MAIL-ORDER PHARMACIES

It is hereby enacted by the General Assembly of the State of Vermont:


Sec. 1.  8 V.S.A. § 4089j is amended to read:

§ 4089j.  RETAIL PHARMACIES; FILLING OF PRESCRIPTIONS

(a)  A health insurer and pharmacy benefit manager doing business in Vermont shall permit a retail pharmacist licensed under chapter 36 of Title 26 to fill prescriptions in the same manner and at the same level of reimbursement as they are filled by mail order pharmacies with respect to the quantity of drugs or days' supply of drugs dispensed under each prescription.

(b)  As used in this section:

(1)  "Health insurer" is defined by subdivision 9402(9) of Title 18.

(2)  "Pharmacy benefit manager" means an entity that performs pharmacy benefit management. "Pharmacy benefit management" means an arrangement for the procurement of prescription drugs at negotiated dispensing rates, the administration or management of prescription drug benefits provided by a health insurance plan for the benefit of beneficiaries, or any of the following services provided with regard to the administration of pharmacy benefits:

(A)  mail service pharmacy;

(B)  claims processing, retail network management, and payment of claims to pharmacies for prescription drugs dispensed to beneficiaries;

(C)  clinical formulary development and management services;

(D)  rebate contracting and administration;

(E)  certain patient compliance, therapeutic intervention, and generic substitution programs; and

(F)  disease management programs.

(c)  This section shall apply to Medicaid, the Vermont health access plan, the VScript pharmaceutical assistance program, and any other public health care assistance program.

A health insurer and pharmacy benefit manager shall give clear and conspicuous written notice of the insured’s rights pursuant to this section, meaning a disclosure that is noticeable, readable, and understandable to the insured is printed as part of any prescription drug benefit description relating to the purchase of prescription drugs from a mail service pharmacy.  The notice shall state that the insured may purchase a supply of a prescription from a community retail pharmacy for the same co-pay as from an insurer-designated mail service pharmacy.

(c)  Verbal notice given to the insured by an agent or the health insurer or pharmacy benefit manger in a live communication or by recorded electronic means shall meet the requirements of subsection (b) of this section.  A health insurer or pharmacy benefit manager is expressly prohibited from making any misrepresentation concerning the ability or willingness of a community retail pharmacy to fill the prescription with the same co-pay as a mail service pharmacy, or to obtain the prescription itself at a lower wholesale cost than a community retail pharmacist, or both.

(d)  A violation of this section shall be deemed a violation of the Consumer Fraud Act, chapter 63 of Title 9.  The attorney general may investigate and prosecute violations of this section pursuant to the provisions of the Consumer Fraud Act.

(e)  As used in this section:

(1)  "Health insurer" is defined by subdivision 9402(9) of Title 18.  As used in this subchapter, the term includes the state of Vermont and any agent or instrumentality of the state that offers, administers, or provides financial support to state government.  It includes Medicaid, the Vermont health access plan, the V-pharm assistance program, the Vermont-Rx program, and any other public health care assistance program.

(2)  “Pharmacy benefit management” means an arrangement for the procurement of prescription drugs at a negotiated rate for dispensation within this state to beneficiaries, the administration or management of prescription drug benefits provided by a health insurance plan for the benefit of beneficiaries, or any of the following services provided with regard to the administration of pharmacy benefits:

(A)  mail service pharmacy;

(B)  claims processing, retail network management, and payment of claims to pharmacies for prescription drugs dispensed to beneficiaries;

(C)  clinical formulary development and management services;

(D)  rebate contracting and administration;

(E)  certain patient compliance, therapeutic intervention, and generic substitution programs; and

(F)  disease management programs.

(3)  “Pharmacy benefit manager” means an entity that performs pharmacy benefit management.  The term includes a person or entity acting for a pharmacy benefit manager in a contractual or employment relationship in the performance of pharmacy benefit management for a health insurance plan.



Published by:

The Vermont General Assembly
115 State Street
Montpelier, Vermont


www.leg.state.vt.us