Signed by Governor Kevin Stitt

Vote Smart's Synopsis:

Vote to pass a bill that establishes the Patient's Right to Pharmacy Choice Act.

Highlights:

• Requires retail pharmacy networks to comply with the following access standards (Sec. 4):

• At least 90 percent of covered individuals in the benefit plan’s urban service area live within 2 miles of a retail pharmacy participating in the benefit plan’s pharmacy network;

• At least 90 percent of covered individuals in the benefit plan’s urban service area live within 5 miles of a retail pharmacy designated as a preferred participating pharmacy in the benefit plan’s retail pharmacy network;

• At least 90 percent of covered individuals in the benefit plan’s suburban service area live within 5 miles of a retail pharmacy participating in the benefit plan’s retail pharmacy network;

• At least 90 percent of covered individuals in the benefit plan’s suburban service area live within 7 miles of a retail pharmacy designated as a preferred participating pharmacy in the benefit plan’s retail pharmacy network;

• At least 70 percent of covered individuals in the benefit plan’s rural service area live within 15 miles of a retail pharmacy participating in the benefit plan’s retail pharmacy network; and

• At least 70 percent of covered individuals in the benefit plan’s rural service area live within 18 miles of a retail pharmacy designated as a preferred participating pharmacy in the benefit plan’s retail pharmacy network.

• Prohibits pharmacy benefits managers (PBM) and benefit plans from requiring patients to use pharmacies that are directly or indirectly owned by the pharmacy benefits manager or benefit plan, including all regular prescriptions, refills or speciality drugs regardless of day supply (Sec. 4).

• Prohibits PBM and benefit plans in any manner on any material,  including mail and ID cards, include the name of any pharmacy, hospital or other providers unless it specifically lists all pharmacies, hospitals and providers participating in the preferred and nonpreferred pharmacy and health networks (Sec. 4).

• Prohibits a PBM, or PBM representative of a PBM from (Sec. 5):

• Causing or knowingly permitting the use of advertisement, promotion, solicitation, representation, proposal of offer that is untrue, deceptive or misleading;

• Charging a pharmacist or pharmacy a fee related to the adjudication of a claim, including without limitation a fee for:

• The submission of a claim;

• Enrollment or participation in a retail pharmacy network; or

• The development or management of claims processing services or claims payment services related to participation in a retail pharmacy network;

• Reimburse an independent pharmacy an amount less than the amount that the PBM reimburses pharmacies owned by the PBM;

• Deny a pharmacy the opportunity to participate in any pharmacy network at preferred participation participation status if the pharmacy is willing to accept the terms and conditions that the PBM has established for other pharmacies as a condition of preferred network participation status;

• Deny, limit, or terminate a pharmacy’s contract based on employment status of any employee who has an active license to dispense, despite probation status, with the State Board of Pharmacy;

• Impose on a covered individual a monetary advantage or penalty, including a higher cost-sharing or additional fee which would affect a covered individual’s choices of network pharmacy;

• Retroactively deny or reduce reimbursement for a covered service claim after returning a paid claim response as part of the adjudication of the claim, unless;

• The original claim was submitted fraudulently; or

• To correct errors identified in an audit, so long as the audit was conducted in compliance with the Oklahoma Statutes; or

• Fail to make any payment due to a pharmacy or pharmacist for covered services properly rendered in the event a PBM terminates a pharmacy or pharmacist from a pharmacy benefits manager network.

• Defines “benefit plan” as any health benefit plan offered by a health insurance carrier, health maintenance organization, managed care entity, or any other entity that provides prescription drug benefits to covered individuals, including workers’ compensation programs, state-administered health plans and self-funded benefit programs.

• Defines “retail pharmacy network” as retail pharmacy providers contracted with the entity providing or administering a benefit plan in which the pharmacy primarily fills and sells prescriptions via a retail, storefront location (Sec. 3).

• Defines “PBM” as an individual, business, or other entity that performs pharmacy benefits management (Sec. 3).

• Defines “rural service area” as a five-digit zip code in which the population density is less than 1,000 individuals per square mile (Sec. 3).

• Defines “suburban service area” as a five-digit zip code in which the population density is between 1,000 and 3,000 individuals per square mile (Sec. 3).

• Defines “urban service area” as a five-digit zip code in which the population density is greater than 3,000 individuals per square mile (Sec. 3).

Full Bill Text