Pending State Maximum Allowable Cost Legislation (2014)
Georgia:
S.B 408 - Would impose certain requirements for the use of maximum allowable cost pricing by Pharmacy Benefit Managers. Such requirements would necessitate that in all contracts or agreements with pharmacists, pharmacies, or other licensed dispensing providers that the MAC methodology, basis of the methodology, and sources used to determine the MAC for each drug. Additionally updates on pricing information to pharmacies, pharmacists, and other licensed dispensing providers will be made available every seven calendar days.
H.B 1026 - Would require that any PBM that uses MAC pricing or MAC list pricing to determine reimbursement for pharmacies and other licensed dispensaries. Additionally the bill would require to allow for an administrative appeals process for the pharmacy or dispensing entity to contest the listed MAC rate as well as require the timely elimination or modification of products on the MAC list to reflect general market condition.
Florida:
S.B. 1014 - Would specify contract terms that must be included in a contract between a PBM and and a pharmacy and provides restrictions on the inclusion of prescription drugs on a list that specifies the MAC for such drugs. Additionally this would require the PBM to disclose certain information to a plan sponsor as well create an appeals process for pharmacies wishing to contest charges or reimbursement with PBMs.
Indiana:
H.B. 1115 - Would regulate Pharmacy Benefit Managers generally as well as lays out guidelines what MAC information must be provided to a Pharmacy. Specifically that a PBM shall provide to pharmacies that it has contracted with the market based sources used to determine the maximum allowable cost price lists of the pharmacy benefits manager at the beginning of each calendar year as well as the updated price information at least every seven calendar days through an agreed upon updating process. Also included were provisions to allow for an agreed upon administrative appeals procedure to allow a pharmacy to appeal a listed maximum allowable cost price.
Iowa:
S.B. 3087 & H.F. 2297 - Would regulate Pharmacy Benefit Managers and require them to provide to Pharmacies information regarding which of the national compendia is used to obtain pricing data used in the calculation of the maximum reimbursement amount (MAC) pricing. It would also mandate the creation of a process to allow a pharmacy to comment on, contest, or appeal the maximum reimbursement amount rates or maximum reimbursement amount list.
Louisiana:
S.B. 410 - Would regulate Pharmacy Benefit Managers and force them to make their Maximum Allowable Costs available to each pharmacy subject to the list. Additionally PBMs must update their MAC list on a timely basis, but in no event longer than seven calendar days from a change in the methodology on which the MAC list is based or in the value of a variable involved in the methodology.
Maine:
H.P. 1196 - Would regulate pricing disclosure requirements of Pharmacy Benefits Managers including requirements surrounding Maximum Allowable Cost. Requires the basis of the methodology and the sources used to establish the MACs used by the PBM to be disclosed at the beginning of each calendar year. Additionally a PBM shall establish a process by which a pharmacy may contest a MAC, the PBM must then respond to the Pharmacy within 15 calendar days.
Maryland:
S.B. 952 & H.B 793 - Would force Pharmacy Benefit Managers to disclose pricing methodology to pharmacies and PSAOs to calculate reimbursement costs for each drug, medical benefit or device that is a covered benefit administered by the PBM. A PBM shall include in its contract information identifying the National Drug pricing compendia or other source used to obtain the drug, medical product, and device price data; and the methodology used to calculate the Maximum Allowable Cost. Additionally a PBM must make a process available through which a Pharmacy may appeal a MAC within 60 days after the date of the original submission. Signed into law on May 5, 2014.
Michigan:
S.B. 656 - Provides MAC transparency for state plans. Requires the Department of Community Health and contracted health plans to use a process for maximum allowable cost pricing reconsiderations that would have to be available and provided to providers and pharmacists. Signed into law on June 16, 2014.
Missouri:
S.B. 895 & H.B. 2152 - Would require that for every drug for which the Pharmacy Benefit Manager establishes a Maximum Allowable Cost to determine the drug product reimbursement, the PBM shall include in the contract with the pharmacy, information identifying the national drug pricing compendia or sources used to obtain the drug price data and the methodology used in preparing the maximum allowable cost. Additionally a PBM must provide a process for each pharmacy subject to the
MAC to receive prompt notification of an update to the MAC list.
Oklahoma:
H.B. 2100 - Would regulate the conduct and transparency of Pharmacy Benefit Manager as well as specify what information they must reveal to pharmacies with whom they contract. Such contracts would include the basis of the methodology and sources utilized to determine the maximum allowable cost pricing of the pharmacy and would require the MAC pricing updated every seven calendar days. Additionally a PBM would be required to provide a reasonable administration appeals procedure to allow a provider to contest MAC rates. Signed into law May 12, 2014.
Oregon:
S.B. 402 - Would require PBMs to specify methodology for determining MAC prices as well as creates a process for adjudication if the pharmacy disputes the MAC price. Also would specify the frequency for which the MAC list must be updated.
Pennsylvania:
S.B 1089 - Would provide the groundwork for the regulation of Pharmacy Benefit Managers generally as well as in their interactions with Pharmacies and other providers. One aspect that was laid out dealt with the Maximum allowable cost list pricing disclosures between a PBM and its contracted pharmacies, specifically that beginning on January 1st of each calendar year, the PBM shall, provide or make readily available the applicable MAC to pharmacies. As well as include the basis of the methodology and sources utilized to determine the MAC.
Rhode Island:
S.B. 2531 & H.B 7643 - Would provide regulators the ability to oversee the business relationships between pharmacy providers and health service organizations. Some of the practices that will be overseen include auditing as well as changes concerning the Maximum Allowable Cost list. Specifically a PBM shall at the beginning of each calendar year disclose to pharmacies it contracts with, the basis of the methodology and the sources used to create the MAC pricing index or MAC rates used by the PBM. Additionally at least once every seven business days, the MAC pricing index or MAC rates used by the PBM.
Texas:
H.B. 1036 - Would regulate Pharmacy Benefit Managers widely in their contractual dealings with Pharmacies. Among the mandated changes include guidelines for how audits must be conducted by PBMs of Pharmacies including when such audits can occur and who must be on present for them to take place. Additionally this law would regulate factors relating to the Maximum Allowable Cost list, among which would be the frequency with which the list is updated and what requirements go into putting a drug on the MAC.
Tennessee:
H.B. 1554 - Would regulate the use of Maximum Allowable Cost lists by Pharmacy Benefit Managers and Covered Entities. The law would require a PBM or covered entity to provide to each pharmacy with which the PBM or Covered entity has a contract the methodology and sources used to determine the MAC for the multi-source generic drugs and medical products and devices on each MAC. Additionally a PBM shall not set the MAC for any multi-source generic drug or medical product or device it places on a MAC list in an amount which is below the amount found in the source used by the PBM to set the cost. Signed into law on May 16, 2014.
Washington:
S.B. 6137 - Would regulate how Pharmacy Benefit Managers operate in the State broadly as well as outlines specifics including how audits are to be conducted and take place as well as details surrounding the application of a Maximum Allowable Cost list. A PBM would be required to make available to each network pharmacy at the beginning of the term of a contract, and upon renewal of a contract, the sources utilized to determine the MAC pricing of the PBM. Additionally a PBM is mandated to update each list every seven business days and make said updated lists available to network pharmacies.
West Virginia:
S.B. 509 - Would regulate Pharmacy Benefits Managers and their conduct with pharmacies through rules and guidelines. If enacted would impose restrictions upon audits conducted by PBMs and provide an internal review process applicable to disputed findings of a PBM upon audit. It would also require PBMs to provide notice to purchasers, pharmacists and pharmacies of information relating to maximum allowable costs as well as require pharmacy benefits managers to provide a process relating to the appropriate use of maximum allowable cost pricing.
S.B 408 - Would impose certain requirements for the use of maximum allowable cost pricing by Pharmacy Benefit Managers. Such requirements would necessitate that in all contracts or agreements with pharmacists, pharmacies, or other licensed dispensing providers that the MAC methodology, basis of the methodology, and sources used to determine the MAC for each drug. Additionally updates on pricing information to pharmacies, pharmacists, and other licensed dispensing providers will be made available every seven calendar days.
H.B 1026 - Would require that any PBM that uses MAC pricing or MAC list pricing to determine reimbursement for pharmacies and other licensed dispensaries. Additionally the bill would require to allow for an administrative appeals process for the pharmacy or dispensing entity to contest the listed MAC rate as well as require the timely elimination or modification of products on the MAC list to reflect general market condition.
Florida:
S.B. 1014 - Would specify contract terms that must be included in a contract between a PBM and and a pharmacy and provides restrictions on the inclusion of prescription drugs on a list that specifies the MAC for such drugs. Additionally this would require the PBM to disclose certain information to a plan sponsor as well create an appeals process for pharmacies wishing to contest charges or reimbursement with PBMs.
Indiana:
H.B. 1115 - Would regulate Pharmacy Benefit Managers generally as well as lays out guidelines what MAC information must be provided to a Pharmacy. Specifically that a PBM shall provide to pharmacies that it has contracted with the market based sources used to determine the maximum allowable cost price lists of the pharmacy benefits manager at the beginning of each calendar year as well as the updated price information at least every seven calendar days through an agreed upon updating process. Also included were provisions to allow for an agreed upon administrative appeals procedure to allow a pharmacy to appeal a listed maximum allowable cost price.
Iowa:
S.B. 3087 & H.F. 2297 - Would regulate Pharmacy Benefit Managers and require them to provide to Pharmacies information regarding which of the national compendia is used to obtain pricing data used in the calculation of the maximum reimbursement amount (MAC) pricing. It would also mandate the creation of a process to allow a pharmacy to comment on, contest, or appeal the maximum reimbursement amount rates or maximum reimbursement amount list.
Louisiana:
S.B. 410 - Would regulate Pharmacy Benefit Managers and force them to make their Maximum Allowable Costs available to each pharmacy subject to the list. Additionally PBMs must update their MAC list on a timely basis, but in no event longer than seven calendar days from a change in the methodology on which the MAC list is based or in the value of a variable involved in the methodology.
Maine:
H.P. 1196 - Would regulate pricing disclosure requirements of Pharmacy Benefits Managers including requirements surrounding Maximum Allowable Cost. Requires the basis of the methodology and the sources used to establish the MACs used by the PBM to be disclosed at the beginning of each calendar year. Additionally a PBM shall establish a process by which a pharmacy may contest a MAC, the PBM must then respond to the Pharmacy within 15 calendar days.
Maryland:
S.B. 952 & H.B 793 - Would force Pharmacy Benefit Managers to disclose pricing methodology to pharmacies and PSAOs to calculate reimbursement costs for each drug, medical benefit or device that is a covered benefit administered by the PBM. A PBM shall include in its contract information identifying the National Drug pricing compendia or other source used to obtain the drug, medical product, and device price data; and the methodology used to calculate the Maximum Allowable Cost. Additionally a PBM must make a process available through which a Pharmacy may appeal a MAC within 60 days after the date of the original submission. Signed into law on May 5, 2014.
Michigan:
S.B. 656 - Provides MAC transparency for state plans. Requires the Department of Community Health and contracted health plans to use a process for maximum allowable cost pricing reconsiderations that would have to be available and provided to providers and pharmacists. Signed into law on June 16, 2014.
Missouri:
S.B. 895 & H.B. 2152 - Would require that for every drug for which the Pharmacy Benefit Manager establishes a Maximum Allowable Cost to determine the drug product reimbursement, the PBM shall include in the contract with the pharmacy, information identifying the national drug pricing compendia or sources used to obtain the drug price data and the methodology used in preparing the maximum allowable cost. Additionally a PBM must provide a process for each pharmacy subject to the
MAC to receive prompt notification of an update to the MAC list.
Oklahoma:
H.B. 2100 - Would regulate the conduct and transparency of Pharmacy Benefit Manager as well as specify what information they must reveal to pharmacies with whom they contract. Such contracts would include the basis of the methodology and sources utilized to determine the maximum allowable cost pricing of the pharmacy and would require the MAC pricing updated every seven calendar days. Additionally a PBM would be required to provide a reasonable administration appeals procedure to allow a provider to contest MAC rates. Signed into law May 12, 2014.
Oregon:
S.B. 402 - Would require PBMs to specify methodology for determining MAC prices as well as creates a process for adjudication if the pharmacy disputes the MAC price. Also would specify the frequency for which the MAC list must be updated.
Pennsylvania:
S.B 1089 - Would provide the groundwork for the regulation of Pharmacy Benefit Managers generally as well as in their interactions with Pharmacies and other providers. One aspect that was laid out dealt with the Maximum allowable cost list pricing disclosures between a PBM and its contracted pharmacies, specifically that beginning on January 1st of each calendar year, the PBM shall, provide or make readily available the applicable MAC to pharmacies. As well as include the basis of the methodology and sources utilized to determine the MAC.
Rhode Island:
S.B. 2531 & H.B 7643 - Would provide regulators the ability to oversee the business relationships between pharmacy providers and health service organizations. Some of the practices that will be overseen include auditing as well as changes concerning the Maximum Allowable Cost list. Specifically a PBM shall at the beginning of each calendar year disclose to pharmacies it contracts with, the basis of the methodology and the sources used to create the MAC pricing index or MAC rates used by the PBM. Additionally at least once every seven business days, the MAC pricing index or MAC rates used by the PBM.
Texas:
H.B. 1036 - Would regulate Pharmacy Benefit Managers widely in their contractual dealings with Pharmacies. Among the mandated changes include guidelines for how audits must be conducted by PBMs of Pharmacies including when such audits can occur and who must be on present for them to take place. Additionally this law would regulate factors relating to the Maximum Allowable Cost list, among which would be the frequency with which the list is updated and what requirements go into putting a drug on the MAC.
Tennessee:
H.B. 1554 - Would regulate the use of Maximum Allowable Cost lists by Pharmacy Benefit Managers and Covered Entities. The law would require a PBM or covered entity to provide to each pharmacy with which the PBM or Covered entity has a contract the methodology and sources used to determine the MAC for the multi-source generic drugs and medical products and devices on each MAC. Additionally a PBM shall not set the MAC for any multi-source generic drug or medical product or device it places on a MAC list in an amount which is below the amount found in the source used by the PBM to set the cost. Signed into law on May 16, 2014.
Washington:
S.B. 6137 - Would regulate how Pharmacy Benefit Managers operate in the State broadly as well as outlines specifics including how audits are to be conducted and take place as well as details surrounding the application of a Maximum Allowable Cost list. A PBM would be required to make available to each network pharmacy at the beginning of the term of a contract, and upon renewal of a contract, the sources utilized to determine the MAC pricing of the PBM. Additionally a PBM is mandated to update each list every seven business days and make said updated lists available to network pharmacies.
West Virginia:
S.B. 509 - Would regulate Pharmacy Benefits Managers and their conduct with pharmacies through rules and guidelines. If enacted would impose restrictions upon audits conducted by PBMs and provide an internal review process applicable to disputed findings of a PBM upon audit. It would also require PBMs to provide notice to purchasers, pharmacists and pharmacies of information relating to maximum allowable costs as well as require pharmacy benefits managers to provide a process relating to the appropriate use of maximum allowable cost pricing.