Prescription drug benefits - real-time access to benefit information - enforcement - definitions - rules

(c) (I) Upon receipt of a request for cost, benefit, and coverage data pursuant to this subsection (1), the carrier or PBM, as applicable, shall provide the following data for any drug covered under the covered person's health benefit plan:

(A) The covered person's eligibility information for the drug;

(B) A list of any clinically appropriate alternatives to the drug that are covered under the covered person's health benefit plan;

(C) Cost-sharing information for the drug and for clinically appropriate alternatives, including a description of any variance in cost-sharing based on a pharmacy, whether retail or mail order, or provider dispensing or administering the drug or alternatives; and

(D) Any applicable utilization management requirements for the drug or clinically appropriate alternatives, including prior authorization, step therapy, quantity limits, and site-of-service restrictions.

(II) The carrier or PBM shall furnish the data specified in subsection (1)(c)(I) of this section, whether the request is made using the drug's unique billing code, such as a national drug code or Healthcare Common Procedure Coding System code, or a descriptive term, such as the brand or generic name of the drug. A carrier or PBM shall not deny or delay a request for cost, benefit, and coverage data as a method of blocking the data from being shared based on how the drug was requested.

(d) A carrier or PBM furnishing the data requested pursuant to this subsection (1) shall not:

(I) Restrict, prohibit, or otherwise hinder a provider from communicating or sharing with the covered person:

(A) Any of the data set forth in subsection (1)(c)(I) of this section;

(B) Additional information on any lower-cost or clinically appropriate alternatives, whether or not the alternatives are covered under the covered person's plan; or

(C) Additional payment or cost-sharing information that may reduce the covered person's out-of-pocket costs, such as cash price or patient assistance and support programs, whether sponsored by a manufacturer, foundation, or other entity;

(II) Except as may be required by law, interfere with, prevent, or materially discourage access, exchange, or use of the data set forth in subsection (1)(c)(I) of this section, which may include:

(A) Charging fees;

(B) Failing to respond to a request, at the time the request is made, when a response is reasonably possible;

(C) Implementing technology in nonstandard ways or instituting covered person consent requirements, processes, policies, procedures, or renewals that are likely to substantially increase the complexity or burden of accessing, exchanging, or using the data; or

(III) Penalize a provider for disclosing the information to a covered person or prescribing, administering, or ordering a clinically appropriate or lower-cost alternative.

(e) A carrier or PBM shall treat a personal representative of a covered person as the covered person for purposes of this section. If, under applicable law, a person has authority to act on behalf of a covered person in making decisions related to health care, a carrier or PBM, or affiliates or entities acting on behalf of the carrier or PBM, must treat the person as a personal representative of the covered person for purposes of this section.

(1.5) With regard to the requirements of this section applicable to PBMs, the commissioner has the authority to enforce this section and to impose a penalty or other remedy against a PBM that fails to comply with this section.

(1.7) The commissioner may adopt rules to implement and enforce this section.

(2) As used in this section, unless the context otherwise requires:

(a) CMS means the federal centers for medicare and medicaid services in the United States department of health and human services.

(b) Cost-sharing information means the amount a covered person is required to pay for a drug that is covered under the covered person's health benefit plan.

(c) Covered or coverage means those health-care services to which a covered person is entitled under the terms of the covered person's health benefit plan.

(d) Drug means any prescription drug or medication covered under a health benefit plan, whether ordered, prescribed, or administered.

(e) Healthcare Common Procedure Coding System means the system developed by the CMS for identifying health-care services in a consistent and standardized manner.

(f) National drug code means the unique, three-segment identifier number used by the FDA to identify drugs that are manufactured, prepared, propagated, compounded, or processed for sale in the United States.

(g) Third party means a person, other than a PBM, that is not an enrollee in or a covered person under a health benefit plan.