SF 2261 (LSB 5745SV (1) 86)

SENATE FILE 2261

BY  COMMITTEE ON COMMERCE

(SUCCESSOR TO SF 2078)

A BILL FOR

An Act relating to and providing insurance coverage for medication synchronization.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  NEW SECTION.  514C.5A  Prescription drug medication synchronization.
   1.  A group policy or contract providing for third-party payment or prepayment for prescription drugs shall permit and apply a prorated daily cost-sharing rate to prescription drugs that are dispensed for less than a thirty-day supply, for the purposes of synchronizing the medications of the person covered under the policy or contract, if the prescriber or pharmacist determines the prorated filling or refilling of the prescription drug to be in the best interest of the person and the person requests or agrees to less than a thirty-day supply. However, the group policy or contract shall not use payment structures incorporating pro rata dispensing fees, and the dispensing fee for partially filled or refilled prescriptions shall be paid based on the full supply of each prescription dispensed, regardless of any prorated copayment paid by the covered person for synchronization of medications. 
   2.  A group policy or contract providing for third-party payment or prepayment for prescription drugs shall not deny coverage for the dispensing of multiple prescriptions at one time for the purposes of synchronizing medications for a covered person under the policy or contract, if the person and the pharmacist or other prescriber agree to synchronizing the filling or refilling of multiple prescriptions for the person. The group policy or contract shall allow a pharmacy to override any denial codes indicating that a prescription drug is being refilled too soon for the purposes of medication synchronization.
   3.  A person who provides an individual policy or contract providing for third-party payment or prepayment of health or medical expenses shall make available a coverage provision that satisfies the requirements of this section in the same manner as such requirements are applicable to a group policy or contract under this section. The policy or contract shall provide that the individual policyholder may reject the coverage provision at the option of the policyholder.
   4.  a.  This section applies to the following classes of third-party payment provider contracts or policies delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2017:
   (1)  Individual or group accident and sickness insurance providing coverage on an expense-incurred basis.
   (2)  An individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.
   (3)  An individual or group health maintenance organization contract regulated under chapter 514B.
   (4)  Any other entity engaged in the business of insurance, risk transfer, or risk retention, which is subject to the jurisdiction of the commissioner.
   (5)  A plan established pursuant to chapter 509A for public employees.
   (6)  An organized delivery system licensed by the director of public health.
   b.  This section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, 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.
EXPLANATION
The inclusion of this explanation does not constitute agreement with

the explanation’s substance by the members of the general assembly.
   This bill relates to insurance coverage for prescription drugs dispensed in a manner to facilitate medication synchronization. The bill requires that a group policy or contract providing for third-party payment or prepayment for prescription drugs apply a prorated daily cost-sharing rate to prescription drugs that are dispensed for less than a 30-day supply, for the purposes of synchronizing the medications of the person covered under the policy or contract, if the prescriber or pharmacist determines the prorated filling or refilling of the prescription drug to be in the best interest of the person and the person requests or agrees to less than a 30-day supply. However, the group policy or contract shall not use payment structures incorporating pro rata dispensing fees, and the dispensing fee for partially filled or refilled prescriptions shall be paid based on the full supply of each prescription dispensed, regardless of any prorated copayment paid by the covered person for synchronization of medications.
   The bill also prohibits a group policy or contract providing for third-party payment or prepayment for prescription drugs from denying coverage for the dispensing of multiple prescriptions at one time for the purposes of synchronizing medications for a covered person under the policy or contract, if the person and the pharmacist or other prescriber agree to synchronizing the filling or refilling of multiple prescriptions for the person. The group policy or contract is required to allow a pharmacy to override any denial codes indicating that a prescription drug is being refilled too soon for the purposes of medication synchronization. 
   The bill requires a person who provides an individual policy or contract providing for third-party payment or prepayment of health or medical expenses to make available a coverage provision that satisfies the requirements of the bill in the same manner as such requirements are applicable to a group policy or contract. The policy or contract shall provide that the individual policyholder may reject the coverage provision at the option of the policyholder.
   The bill specifies the classes of third-party payment provider contracts or policies delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2017, to which the bill applies or does not apply.