HSB 511 (LSB 5295YC (1) 83)

HOUSE FILE _____

BY  (PROPOSED COMMITTEE ON HUMAN RESOURCES BILL BY CHAIRPERSON SMITH)

A BILL FOR

An Act relating to benefit coverage for medication therapy management.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  NEW SECTION.  514C.26  Medication therapy management coverage.
   1.  As used in this section:
   a.  “Commissioner” means the commissioner of insurance.
   b.  “Medication therapy management” means a systematic process performed by a licensed pharmacist, designed to optimize therapeutic outcomes through improved medication use and reduced risk of adverse drug events, including all of the following services:
   (1)  A medication therapy review of all medications currently being taken by an individual.
   (2)  A medication action plan communicated to the individual and the individual’s primary care physician or other appropriate prescriber to address safety issues, inconsistencies, duplicative therapy, omissions, and medication costs. The medication action plan may include recommendations to the prescriber for changes in drug therapy.
   (3)  Documentation and follow-up to ensure consistent levels of pharmacy services and positive outcomes.
   2.  Notwithstanding the uniformity of treatment requirements of section 514C.6, a contract, policy, or plan providing for third-party payment or prepayment for health or medical expenses that include pharmaceutical benefits shall provide coverage for medication therapy management in accordance with rules adopted by the commissioner. The provisions of this section shall apply to all of the following classes of third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state on or after July 1, 2010:
   a.  Individual or group accident and sickness insurance providing coverage on an expense-incurred basis.
   b.  An individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.
   c.  An individual or group health maintenance organization contract regulated under chapter 514B.
   d.  An individual or group Medicare supplemental policy, unless coverage pursuant to such policy is preempted by federal law.
   e.  A plan established pursuant to chapter 509A for public employees.
   3.  This section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, long-term care, basic hospital, and medical-surgical expense coverage as defined by the commissioner, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance.
   4.  The commissioner shall adopt rules pursuant to chapter 17A regarding coverage of benefits for medication therapy management based on all of the following:
   a.  Medication therapy management shall be a covered benefit for any of the following individuals:
   (1)  An individual who takes four or more prescription drugs to treat or prevent two or more chronic medical conditions.
   (2)  An individual who has a prescription drug therapy problem as identified by the prescribing physician or other appropriate prescriber, and is referred to a pharmacist for medication therapy management.
   (3)  An individual who meets other criteria established by the commissioner by rule in consultation with the director of public health.
   (4)  An individual who meets other criteria established by the third-party payment provider contract, policy, or plan which is not inconsistent with or more restrictive than the criteria otherwise specified in this paragraph “a”.
   b.  Reimbursement of medication therapy management services shall be separate from the reimbursement for prescription drug product or dispensing services; shall be determined by each third-party payment provider contract, policy, or plan; and shall be reasonably based on the resources and time required to provide the services.
   c.  If any part of the medication therapy management services provided by a pharmacist incorporates services which are outside the pharmacist’s independent scope of practice including the initiation of therapy, modification of dosages, therapeutic interchange, or changes in drug therapy, the express authorization of the individual’s physician or other appropriate prescriber is required. Express authorization includes but is not limited to a collaborative practice agreement.
EXPLANATION
   This bill relates to medication therapy management. The bill defines “medication therapy management” and provides that a contract, policy, or plan providing for third-party payment or prepayment which includes coverage for health or medical expenses that includes pharmaceutical benefits shall provide coverage for medication therapy management in accordance with rules adopted by the commissioner of insurance. The bill specifies the classes of third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state on or after July 1, 2010, that must include or that are exempt from providing coverage for medication therapy management. The bill directs the commissioner of insurance to adopt rules pursuant to Code chapter 17A regarding coverage of benefits for medication therapy management based on specific provisions.