HF 1257

1st Engrossment - 91st Legislature (2019 - 2020) Posted on 05/03/2020 01:53pm

A bill for an act
relating to health care coverage; requiring prescription drug benefit transparency
and disclosure; amending Minnesota Statutes 2018, section 256B.69, subdivision
6; proposing coding for new law in Minnesota Statutes, chapter 62Q.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

Section 1.

new text begin [62Q.83] PRESCRIPTION DRUG BENEFIT TRANSPARENCY AND
MANAGEMENT.
new text end

new text begin Subdivision 1. new text end

new text begin Definitions. new text end

new text begin (a) For purposes of this section, the following terms have
the meanings given them.
new text end

new text begin (b) "Drug" has the meaning given in section 151.01, subdivision 5.
new text end

new text begin (c) "Enrollee contract term" means the 12-month term during which benefits associated
with health plan company products are in effect. For managed care plans and county-based
purchasing plans under section 256B.69 and chapter 256L, it means a single calendar quarter.
new text end

new text begin (d) "Formulary" means a list of prescription drugs that have been developed by clinical
and pharmacy experts and represents the health plan company's medically appropriate and
cost-effective prescription drugs approved for use.
new text end

new text begin (e) "Health plan company" has the meaning given in section 62Q.01, subdivision 4, and
includes an entity that performs pharmacy benefits management for the health plan company.
new text end

new text begin (f) "Pharmacy benefits management" means the administration or management of
prescription drug benefits provided by the health plan company for the benefit of its enrollees
and may include but is not limited to procurement of prescription drugs, clinical formulary
development and management services, claims processing, and rebate contracting and
administration.
new text end

new text begin (g) "Prescription" has the meaning given in section 151.01, subdivision 16a.
new text end

new text begin Subd. 2. new text end

new text begin Prescription drug benefit disclosure. new text end

new text begin (a) A health plan company that provides
prescription drug benefit coverage and uses a formulary must make its formulary and related
benefit information available by electronic means and, upon request, in writing at least 30
days prior to annual renewal dates.
new text end

new text begin (b) Formularies must be organized and disclosed consistent with the most recent version
of the United States Pharmacopeia's Model Guidelines.
new text end

new text begin (c) For each item or category of items on the formulary, the specific enrollee benefit
terms must be identified, including enrollee cost-sharing and expected out-of-pocket costs.
new text end

new text begin Subd. 3. new text end

new text begin Formulary changes. new text end

new text begin (a) Once a formulary has been established, a health plan
company may, at any time during the enrollee's contract term:
new text end

new text begin (1) expand its formulary by adding drugs to the formulary;
new text end

new text begin (2) reduce co-payments or coinsurance; or
new text end

new text begin (3) move a drug to a benefit category that reduces an enrollee's cost.
new text end

new text begin (b) A health plan company may remove a brand name drug from its formulary or place
a brand name drug in a benefit category that increases an enrollee's cost only upon the
addition to the formulary of a generic or multisource brand name drug rated as therapeutically
equivalent according to the Food and Drug Administration (FDA) Orange Book or a biologic
drug rated as interchangeable according to the FDA Purple Book at a lower cost to the
enrollee and upon at least a 60-day notice to prescribers, pharmacists, and affected enrollees.
new text end

new text begin (c) A health plan company may change utilization review requirements or move drugs
to a benefit category that increases an enrollee's cost during the enrollee's contract term
upon at least a 60-day notice to prescribers, pharmacists, and affected enrollees, provided
that these changes do not apply to enrollees who are currently taking the drugs affected by
these changes for the duration of the enrollee's contract term.
new text end

new text begin (d) A health plan company may remove any drugs from its formulary that have been
deemed unsafe by the FDA; that have been withdrawn by either the FDA or the product
manufacturer; or when an independent source of research, clinical guidelines, or
evidence-based standards has issued drug-specific warnings or recommended changes in
drug usage.
new text end

Sec. 2.

Minnesota Statutes 2018, section 256B.69, subdivision 6, is amended to read:

Subd. 6.

Service delivery.

(a) Each demonstration provider shall be responsible for the
health care coordination for eligible individuals. Demonstration providers:

(1) shall authorize and arrange for the provision of all needed health services including
but not limited to the full range of services listed in sections 256B.02, subdivision 8, and
256B.0625 in order to ensure appropriate health care is delivered to enrollees.
Notwithstanding section 256B.0621, demonstration providers that provide nursing home
and community-based services under this section shall provide relocation service coordination
to enrolled persons age 65 and over;

(2) shall accept the prospective, per capita payment from the commissioner in return for
the provision of comprehensive and coordinated health care services for eligible individuals
enrolled in the program;

(3) may contract with other health care and social service practitioners to provide services
to enrollees; and

(4) shall institute recipient grievance procedures according to the method established
by the project, utilizing applicable requirements of chapter 62D. Disputes not resolved
through this process shall be appealable to the commissioner as provided in subdivision 11.

(b) Demonstration providers must comply with the standards for claims settlement under
section 72A.201, subdivisions 4, 5, 7, and 8, when contracting with other health care and
social service practitioners to provide services to enrollees. A demonstration provider must
pay a clean claim, as defined in Code of Federal Regulations, title 42, section 447.45(b),
within 30 business days of the date of acceptance of the claim.

new text begin (c) Managed care plans and county-based purchasing plans must comply with section
62Q.83.
new text end