HB 192: Enact the Community Pharmacy Protection Act

As Introduced

36th General Assembly

Regular Session H. B. No. 192

Representatives Barhorst, Fischer

Cosponsors: Representatives McClain, Gross, Dean, Johnson, Mullins, Odioso

A B I L L

To amend section 3902.50 and to enact sections 1
3902.75, 3902.76, and 3959.151 of the Revised 2
Code to limit insurer accreditation requirements 3
for pharmacies, to implement drug cost reporting 4
requirements for pharmacy benefit managers, and 5
to name this act the Community Pharmacy 6
Protection Act. 7

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:

Section 1. That section 3902.50 be amended and sections 8
3902.75, 3902.76, and 3959.151 of the Revised Code be enacted to 9
read as follows: 10
Sec. 3902.50. As used in sections 3902.50 to 3902.72 11
3902.76 of the Revised Code: 12
(A) "Ambulance" has the same meaning as in section 4765.01 13
of the Revised Code. 14
(B) "Clinical laboratory services" has the same meaning as 15
in section 4731.65 of the Revised Code. 16

(C) "Cost sharing" means the cost to a covered person 17

H. B. No. 192 As Introduced

under a health benefit plan according to any copayment, 18
coinsurance, deductible, or other out-of-pocket expense 19
requirement. 20
(D) "Covered" or "coverage" means the provision of 21
benefits related to health care services to a covered person in 22
accordance with a health benefit plan. 23
(E) "Covered person," "health benefit plan," "health care 24
services," and "health plan issuer" have the same meanings as in 25
section 3922.01 of the Revised Code. 26
(F) "Drug" has the same meaning as in section 4729.01 of 27
the Revised Code. 28
(G) "Emergency facility" has the same meaning as in 29
section 3701.74 of the Revised Code. 30
(H) "Emergency services" means all of the following as 31
described in 42 U.S.C. 1395dd: 32
(1) Medical screening examinations undertaken to determine 33
whether an emergency medical condition exists; 34
(2) Treatment necessary to stabilize an emergency medical 35
condition; 36
(3) Appropriate transfers undertaken prior to an emergency 37
medical condition being stabilized. 38
(I) "Health care practitioner" has the same meaning as in 39
section 3701.74 of the Revised Code. 40
(J) "Pharmacy benefit manager" has the same meaning as in 41
section 3959.01 of the Revised Code. 42
(K) "Prior authorization requirement" means any practice 43
implemented by a health plan issuer in which coverage of a 44

H. B. No. 192 As Introduced

ealth care service, device, or drug is dependent upon a covered 45
person or a provider obtaining approval from the health plan 46
issuer prior to the service, device, or drug being performed, 47
received, or prescribed, as applicable. "Prior authorization 48
equirement" includes prospective or utilization review 49
procedures conducted prior to providing a health care service, 50
evice, or drug. 51
(L) "Unanticipated out-of-network care" means health care 52
services, including clinical laboratory services, that are 53
overed under a health benefit plan and that are provided by an 54
out-of-network provider when either of the following conditions 55
pplies: 56
(1) The covered person did not have the ability to request 57
such services from an in-network provider. 58
(2) The services provided were emergency services. 59
Sec. 3902.75. (A) As used in sections 3902.75 and 3902.76 60
f the Revised Code: 61
(1) Notwithstanding section 3902.50 of the Revised Code, 62
"health plan issuer" has the same meaning as in section 3922.01 63
of the Revised Code but also includes an auditing entity, as 64
defined in section 3901.81 of the Revised Code. 65
(2) "Pharmacy" has the same meaning as in section 4729.01 66
of the Revised Code and also includes a dispensing physician. 67
(B) A health plan issuer that offers, issues, or 68
dministers a health benefit plan that covers pharmacy services, 69
ncluding prescription drug coverage, shall not require a 70
harmacy, as a condition of participation in the health plan 71
ssuer's network, to meet accreditation standards or 72
certification requirements that are inconsistent with or in 73

H. B. No. 192 As Introduced

addition to those of the state board of pharmacy. 74

(C) In addition to any other remedies provided by law, any 75
covered person or pharmacy affected by a violation of this 76
section may file a formal complaint with the superintendent of 77
insurance. 78
Sec. 3902.76. (A) The superintendent of insurance shall 79
evaluate any complaint filed under section 3902.75 of the 80
Revised Code. 81
(B)(1) If the superintendent determines, based on a 82
complaint by a covered person or pharmacy or other information 83
available to the superintendent, that a health plan issuer or 84
one or more of the health plan issuer's intermediaries has 85
violated section 3902.75 of the Revised Code, the superintendent 86
shall do both of the following: 87
(a) Issue a notice of violation to the health plan issuer 88
or intermediary that clearly explains the violation; 89
(b) Impose an administrative penalty on the health plan 90
issuer or intermediary of one thousand dollars for each 91
violation. 92
(2) Each day that a violation of section 3902.75 of the 93
Revised Code continues after the health plan issuer or 94
intermediary receives notice of violation under division (B)(1) 95
(a) of this section is considered a separate violation for the 96
purposes of the administrative penalty under division (B)(1)(b) 97
of this section. 98
(C) Before imposing an administrative penalty under this 99
section, the superintendent shall afford the health plan issuer 100
or intermediary an opportunity for an adjudication hearing under 101
Chapter 119. of the Revised Code. At the hearing, the health 102

H. B. No. 192 As Introduced

plan issuer or intermediary may challenge the superintendent's 10
determination that a violation occurred, the superintendent's 10
imposition of an administrative penalty, or both. The health 10
plan issuer or intermediary may appeal the superintendent's 10
determination and imposition of an administrative penalty in 10
accordance with section 119.12 of the Revised Code. 10

(D) An administrative penalty collected under this section shall be deposited into the state treasury to the credit of the department of insurance operating fund created by section 3901.021 of the Revised Code.

Sec. 3959.151. (A) As used in this section, "machinereadable format" means a digital representation of information in a file that can be imported or read into a computer system for further processing. "Machine-readable format" includes.XML and.CSV formats.

(B)(1) Each pharmacy benefit manager shall quarterly 118
provide to the superintendent of insurance and to the pharmacy 119
benefit manager's contracted insurers and plan sponsors, 120
including contracted public employee benefit plans and 121
contracted employers offering a self-insurance program, an 122
electronic report of all drug claims processed the previous 123
quarter in a machine-readable format that is also readable in 124
plain language without the use of software. 125

(2) The electronic report provided to an insurer, a plan sponsor, or the medicaid program shall include an itemized list of the maximum allowable cost of each drug product from all drug product claims processed by the pharmacy benefit manager in the previous quarter for that insurer, that plan sponsor, or the medicaid program. The electronic report provided to the superintendent of insurance shall include an itemized list of

H. B. No. 192 As Introduced

the actual acquisition cost of each drug product from all drug 133
product claims processed by the pharmacy benefit manager in the 134
previous quarter for all insurers and plan sponsors. 135
(3) The itemized list shall notate the following for each 136
drug product: 137
(a) If the drug was procured pursuant to the pharmacy 138
benefit manager, insurer, plan sponsor, or department of 139
medicaid's drug formulary or list of covered drugs; 140
(b) If the drug was procured outside of the drug formulary 141
or list of covered drugs; 142
(c) If the drug is a brand-name drug; 143
(d) If the drug is a generic drug; 144
(e) If the drug is a specialty drug, including biological 145
products. 146
(C)(1) No agreement between a pharmacy benefit manager and 147
an insurer or plan sponsor, including a service agreement under 148
section 3959.15 of the Revised Code, that is entered into, 149
amended, or renewed on or after the effective date of this 150
section shall prohibit disclosure of any of the information 151
included in the itemized list required by division (B) of this 152
section. 153
(2) Notwithstanding division (B) of this section, a 154
pharmacy benefit manager is not required to disclose information 155
deemed proprietary or confidential by a service agreement 156
between the pharmacy benefit manager and an insurer or plan 157
sponsor that is entered into in accordance with section 3959.15 158
of the Revised Code before the effective date of this section, 159
and in effect on the date the information would otherwise be 160

H. B. No. 192 As Introduced

submitted as part of the itemized list required by division (B) 161
of this section. 162
(D) No pharmacy benefit manager shall retaliate against a 163
pharmacy in this state that reports an alleged violation of this 164
section or exercises a right or remedy under this section, by 165
doing any of the following: 166
(1) Terminating or refusing to renew a contract with the 167
pharmacy without providing notice to the pharmacy at least 168
ninety days in advance; 169
(2) Subjecting a pharmacy to increased audits without 170
providing notice to the pharmacy and a detailed description of 171
reason for the audit at least ninety days in advance; 172
(3) Failing to promptly pay a pharmacy in accordance with 173
sections 3901.381 to 3901.3814 of the Revised Code. 174
(E) If a pharmacy in this state believes that a pharmacy 175
benefit manager has violated this section, in addition to any 176
other remedies provided by law, a pharmacy may file a formal 177
complaint and provide evidence related to the complaint to the 178
superintendent of insurance. 179
(F) The superintendent of insurance shall adopt rules in 180
accordance with Chapter 119. of the Revised Code for the 181
purposes of implementing and administering this section. 182
Notwithstanding any provision of section 121.95 of the Revised 183
Code to the contrary, a regulatory restriction contained in a 184
rule adopted by the superintendent in accordance with this 185
section is not subject to sections 121.95 to 121.953 of the 186
Revised Code. 187
Section 2. That existing section 3902.50 of the Revised 188

Code is hereby repealed.

189

H. B. No. 192 As Introduced

Section 3. Sections 3902.75 and 3902.76 of the Revised 190
Code, as enacted in this act, apply to health benefit plans, as 191
defined in section 3922.01 of the Revised Code, delivered, 192
issued for delivery, modified, or renewed on or after the 193
effective date of those sections. 194
Section 4. Sections 3902.75 and 3902.76 of the Revised 195
Code, as enacted in this act, apply to contracts between health 196
plan issuers, as defined in section 3922.01 of the Revised Code, 197
and pharmacies entered into, modified, or renewed on or after 198
the effective date of those sections. 199
Section 5. This act shall be known as the Community 200
Pharmacy Protection Act. 201