Senate
File
554
-
Introduced
SENATE
FILE
554
BY
COMMITTEE
ON
WAYS
AND
MEANS
(SUCCESSOR
TO
SF
284)
A
BILL
FOR
An
Act
relating
to
pharmacy
benefits
manager
reverse
auctions
1
and
group
insurance
for
public
employees.
2
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
3
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1509SV
(1)
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S.F.
554
Section
1.
NEW
SECTION
.
8A.319
Pharmacy
benefits
manager
1
reverse
auctions.
2
1.
This
section
may
be
cited
as
“The
Iowa
Competitive
3
Pharmacy
Benefits
Managers
Marketplace
Act”
.
4
2.
As
used
in
this
section,
unless
the
context
otherwise
5
requires:
6
a.
“Market
check”
means
a
technology-driven
evaluation
of
an
7
incumbent
pharmacy
benefits
manager’s
prescription
drug
pricing
8
based
on
benchmark
comparators
derived
from
pharmacy
benefits
9
manager
reverse
auction
processes
conducted
in
the
United
10
States
over
the
immediately
preceding
twelve
months.
11
b.
“Participant
bidding
agreement”
means
an
online
12
agreement
that
details
common
definitions,
prescription
drug
13
classifications,
rules,
data
access
and
use
rights,
and
other
14
optimal
contract
terms
that
benefit
the
state
and
that
all
15
bidders
must
accept
as
a
prerequisite
for
participation
in
a
16
pharmacy
benefits
manager
reverse
auction.
17
c.
“Pharmacy
benefits
manager”
means
the
same
as
defined
in
18
section
510B.1.
19
d.
“Pharmacy
benefits
manager
reverse
auction”
means
an
20
automated,
transparent,
and
competitive
bidding
process
21
conducted
online
that
starts
with
an
opening
round
of
bids
22
and
allows
qualified
pharmacy
benefits
manager
bidders
to
23
counteroffer
a
lower
price
for
as
many
rounds
of
bidding
24
as
determined
by
the
department
for
a
multiple
health
plan
25
prescription
drug
purchasing
group.
26
e.
“Price”
means
the
projected
cost
of
a
pharmacy
benefits
27
manager’s
bid
to
provide
prescription
drug
benefits
to
allow
28
direct
comparison
of
the
comparably
calculated
costs
of
29
competing
pharmacy
benefits
managers’
proposals
over
the
30
duration
of
the
pharmacy
benefits
manager’s
services
contract.
31
f.
“Real-time”
means
within
no
more
than
one
hour.
32
g.
“Self-funded
private
sector
health
plan”
means
any
33
self-funded
private
sector
employer
or
multi-employer
health
34
plan.
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h.
“Self-funded
public
sector
health
plan”
means
any
group
1
benefit
plan
under
chapter
509A.
2
3.
Consistent
with
section
8A.311,
and
notwithstanding
any
3
other
law
to
the
contrary,
the
department
shall
enter
into
a
4
contract
for
the
services
of
a
pharmacy
benefits
manager
for
5
the
administration
of
benefits
of
self-funded
public
sector
6
health
plans
in
compliance
with
this
section.
7
4.
Prior
to
November
1,
2024,
the
department
shall
8
procure,
through
solicitation
of
proposals
from
qualified
9
professional
services
vendors,
all
of
the
following
based
on
10
price,
capabilities,
and
other
factors
deemed
relevant
by
the
11
department:
12
a.
A
technology
platform
with
the
capabilities
to
conduct
13
a
pharmacy
benefits
manager
reverse
auction.
The
department
14
shall
ensure
that
the
technology
platform
possesses,
at
a
15
minimum,
the
capacity
to
do
all
of
the
following:
16
(1)
Conduct
an
automated,
online,
reverse
auction
of
17
pharmacy
benefits
manager
services
using
a
software
application
18
and
high-performance
data
infrastructure
to
intake,
cleanse,
19
and
normalize
pharmacy
benefits
manager
data
with
development
20
methods
and
information
security
standards
that
have
been
21
validated
by
receiving
service
organization
control
2
and
22
national
institute
of
standards
and
technology
certification,
23
or
successor
information
technology
security
certifications,
as
24
identified
by
the
office
of
the
chief
information
officer.
25
(2)
Automate
repricing
of
diverse
and
complex
pharmacy
26
benefits
managers’
prescription
drug
pricing
proposals
to
allow
27
direct
comparison
by
the
state
of
the
comparably
calculated
28
costs
of
pharmacy
benefits
managers’
bids
using
one
hundred
29
percent
of
annual
prescription
drug
claims
data
available
30
for
state-funded
health
plans,
or
a
multiple
health
plan
31
prescription
drug
purchasing
group,
and
using
code-based
32
classification
of
drugs
from
nationally
accepted
drug
sources.
33
(3)
Simultaneously
evaluate
in
real-time
diverse
and
34
complex
multiple
proposals
from
full-service
pharmacy
benefits
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managers,
including
average
wholesale
price,
guaranteed
1
net
cost,
and
national
average
drug
acquisition
cost
2
pricing
models,
as
well
as
proposals
from
pharmacy
benefits
3
administrators
and
specialty
drug
and
rebate
carve-out
service
4
providers.
5
(4)
Produce
an
automated
report
and
analysis
of
pharmacy
6
benefits
managers’
bids,
including
ranking
of
pharmacy
benefits
7
managers’
bids
based
on
comparative
costs
and
qualitative
8
aspects
of
the
bids
in
real-time
following
the
close
of
each
9
round
of
reverse
auction
bidding.
10
(5)
Perform
real-time,
electronic,
line-by-line,
11
claim-by-claim
review
of
one
hundred
percent
of
invoiced
12
pharmacy
benefits
managers’
prescription
drug
claims,
and
13
identify
all
deviations
from
the
specific
terms
of
the
pharmacy
14
benefits
manager’s
services
contract
that
resulted
from
the
15
reserve
auction
process.
16
b.
Related
services
from
the
operator
of
the
technology
17
platform
identified
in
paragraph
“a”
,
which
at
a
minimum
shall
18
include
all
of
the
following:
19
(1)
Evaluation
of
the
qualifications
of
pharmacy
benefits
20
manager
bidders.
21
(2)
Pharmacy
benefits
manager
reverse
auction
services
to
22
support
the
department
in
comparing
pricing
for
the
pharmacy
23
benefits
manager
procurement.
24
(3)
Related
professional
services.
25
5.
The
department
shall
not
award
a
contract
for
the
26
technology
platform
and
technology
operator
services
to
a
27
vendor
that
is
a
pharmacy
benefits
manager
or
to
a
vendor
that
28
is
managed
by,
or
a
subsidiary
or
affiliate
of,
a
pharmacy
29
benefits
manager.
30
6.
The
vendor
awarded
the
contract
by
the
department
shall
31
not
outsource
any
part
of
the
pharmacy
benefits
manager
reverse
32
auction
or
any
part
of
the
automated,
real-time,
electronic,
33
line-by-line,
claim-by-claim
review
of
invoiced
pharmacy
34
benefits
manager
prescription
drug
claims.
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7.
With
technical
assistance
and
support
provided
by
the
1
technology
platform
operator,
the
department
shall
specify
the
2
terms
of
the
participant
bidding
agreement.
The
terms
of
the
3
participant
bidding
agreement
shall
not
be
modified
except
by
4
specific
consent
of
the
department.
5
8.
a.
The
technology
platform
used
to
conduct
the
reverse
6
auction
shall
be
repurposed
over
the
duration
of
the
pharmacy
7
benefits
manager’s
services
contract
as
an
automated
pharmacy
8
claims
adjudication
engine
to
perform
real-time,
electronic,
9
line-by-line,
claim-by-claim
review
of
one
hundred
percent
of
10
invoiced
pharmacy
benefits
manager’s
prescription
drug
claims,
11
and
to
identify
all
deviations
from
the
specific
terms
of
the
12
pharmacy
benefits
manager’s
services
contract.
13
b.
The
department
shall
reconcile
the
electronically
14
adjudicated
pharmacy
claims,
as
described
in
paragraph
“a”
,
15
with
pharmacy
benefits
manager’s
invoices
on
a
monthly
or
16
quarterly
basis
to
ensure
that
state
payments
shall
not
exceed
17
the
terms
specified
in
any
pharmacy
benefits
manager’s
services
18
contract.
19
c.
If
following
state
payment
to
the
pharmacy
benefits
20
manager
on
the
basis
of
the
reconciliation
under
paragraph
21
“b”
the
pharmacy
benefits
manager
asserts
that
the
department
22
paid
less
than
the
amount
owed,
the
pharmacy
benefits
manager
23
may
seek
resolution
through
a
mutually
acceptable
dispute
24
resolution
process
that
the
parties
agreed
to
in
the
terms
of
25
the
services
contract
under
subsection
9,
paragraph
“a”
.
26
9.
a.
The
first
pharmacy
benefits
manager
reverse
auction
27
shall
be
completed
and
the
services
contract
shall
be
awarded
28
to
the
winning
pharmacy
benefits
manager
with
an
effective
date
29
beginning
July
1,
2024.
Subsequent
contracts
must
be
awarded
30
no
later
than
three
months
prior
to
termination
or
expiration
31
of
the
current
pharmacy
benefits
manager’s
services
contract
32
for
a
covered
group,
such
as
the
state
employees
benefits
33
group,
that
includes
only
active
employees
and
dependents,
but
34
does
not
include
retiree
participants
in
a
Medicare
part
D
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employer
group
waiver
program
pursuant
to
the
federal
Medicare
1
Prescription
Drug,
Improvement,
and
Modernization
Act
of
2003,
2
Pub.
L.
No.
108-173.
3
b.
In
the
event
an
eligible
covered
group
that
includes
4
retiree
participants
in
a
Medicare
part
D
employer
group
5
waiver
program
pursuant
to
the
federal
Medicare
Prescription
6
Drug,
Improvement,
and
Modernization
Act
of
2003,
Pub.
L.
No.
7
108-173,
opts
to
use
the
processes
and
procedures
under
this
8
section,
the
relevant
pharmacy
benefits
manager
reverse
auction
9
shall
be
completed
and
the
pharmacy
benefits
manager
services
10
contract
shall
be
awarded
to
the
winning
pharmacy
benefits
11
manager
no
later
than
six
months
prior
to
termination
or
12
expiration
of
the
pharmacy
benefits
manager’s
services
contract
13
currently
covering
the
retiree
employer
group
waiver
program
14
participants.
15
10.
The
department
may
perform
a
market
check
for
providing
16
pharmacy
benefits
manager
services
during
the
term
of
the
17
current
pharmacy
benefits
manager’s
services
contract
in
order
18
to
ensure
continuing
competitiveness
of
incumbent
prescription
19
drug
pricing
during
the
term
of
a
pharmacy
benefits
manager’s
20
services
contract.
21
11.
To
ensure
that
the
department
does
not
incur
additional
22
expenditures
associated
with
the
pharmacy
benefits
manager
23
reverse
auction,
ongoing
electronic
review
and
validation
24
of
pharmacy
benefits
managers’
claims,
and
periodic
market
25
checks,
the
department
shall
implement
a
no-pay
option
that
26
obligates
the
winning
pharmacy
benefits
manager,
rather
than
27
the
state,
to
pay
the
cost
of
the
technology
platform
and
28
related
technology
platform
operator
services
by
assessing
the
29
pharmacy
benefits
manager
a
per-prescription
fee
in
an
amount
30
agreed
to
by
the
department
and
the
technology
operator,
and
31
requiring
the
pharmacy
benefits
manager
to
pay
the
fees
to
the
32
technology
operator
over
the
duration
of
the
pharmacy
benefits
33
manager’s
services
contract.
The
obligation
of
the
winning
34
pharmacy
benefits
manager
to
pay
the
per-prescription
fee
shall
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be
incorporated
as
a
term
of
the
participant
bidding
agreement
1
and
the
pharmacy
benefits
manager’s
services
contract
awarded
2
to
the
pharmacy
benefits
manager
reverse
auction
winner.
3
12.
a.
This
section
shall
apply
to
group
benefit
plans
4
under
chapter
509A.
This
section
shall
not
apply
to
nonprofit,
5
nongovernmental
health
maintenance
organizations
with
respect
6
to
managed
care
plans
that
provide
a
majority
of
covered
health
7
care
services
through
a
single
contracted
medical
group.
8
b.
After
completion
of
the
first
pharmacy
benefits
manager
9
reverse
auction,
self-funded
private
sector
health
plans
with
10
substantial
participation
by
Iowa
employees
and
the
employees’
11
dependents
shall
have
the
option
to
participate
in
a
joint
12
purchasing
pool
with
state
employees
for
subsequent
pharmacy
13
benefits
manager
reverse
auctions.
14
c.
Any
self-funded
public
sector
health
plans
or
self-funded
15
private
sector
health
plans
that
opt
to
participate
with
16
the
state
employees
group
benefits
plan
in
a
joint
pharmacy
17
benefits
manager
reverse
auction
purchasing
pool
shall
retain
18
full
autonomy
over
determination
of
the
individual
health
19
plan’s
respective
prescription
drug
formularies
and
pharmacy
20
benefit
designs,
and
shall
not
be
required
to
adopt
a
common
21
prescription
drug
formulary
or
common
prescription
pharmacy
22
benefit
design.
Any
such
entity
or
purchasing
group
shall
23
agree,
before
participating
in
the
pharmacy
benefits
manager
24
reverse
auction,
to
accept
the
prescription
drug
pricing
plan
25
that
is
selected
through
a
pharmacy
benefits
manager
reverse
26
auction
process.
27
d.
Any
pharmacy
benefits
manager
providing
services
to
the
28
department,
to
a
self-funded
public
sector
health
plan,
or
29
to
a
self-funded
private
sector
health
plan
as
described
in
30
this
section
shall
provide
the
department,
each
participating
31
self-funded
public
sector
health
plan,
and
each
participating
32
self-funded
private
sector
health
plan
access
to
complete
33
pharmacy
claims
data
necessary
to
conduct
the
pharmacy
34
benefits
manager
reverse
auction
and
to
carry
out
applicable
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administrative
and
management
duties.
1
13.
Notwithstanding
subsection
3,
the
department
may
elect
2
to
vacate
the
outcome
of
a
pharmacy
benefits
manager
reverse
3
auction
if
the
lowest-cost
pharmacy
benefits
manager’s
bid
4
is
not
less
than
the
projected
cost
trend
for
the
incumbent
5
pharmacy
benefits
manager’s
services
contract
as
verified
by
6
the
department.
The
department
may
utilize
a
consultant
to
7
conduct
the
verification.
The
cost
trend
shall
be
projected
8
by
the
technology
platform
operator
using
industry-recognized
9
data
sources
and
shall
be
subject
to
review
and
approval
by
10
the
department
in
advance
of
the
pharmacy
benefits
manager
11
reverse
auction.
Methodology
shall
be
applied
consistently
in
12
projection
of
cost
and
savings
to
the
state
with
regard
to
the
13
incumbent
pharmacy
benefits
manager’s
services
contract
and
14
competing
pharmacy
benefits
manager
reverse
auction
bids.
15
EXPLANATION
16
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
17
the
explanation’s
substance
by
the
members
of
the
general
assembly.
18
This
bill
relates
to
pharmacy
benefits
manager
reverse
19
auctions
and
group
insurance
for
public
employees.
20
“Pharmacy
benefits
manager
reverse
auction”
(reverse
21
auction)
is
defined
in
the
bill
as
an
automated,
transparent,
22
and
competitive
bidding
process
conducted
online
that
starts
23
with
an
opening
round
of
bids
and
allows
qualified
pharmacy
24
benefits
manager
(PBM)
bidders
to
counter-offer
a
lower
price
25
for
as
many
rounds
of
bidding
as
determined
by
the
department
26
of
administrative
services
(DAS)
for
a
multiple
health
plan
27
prescription
drug
purchasing
group.
“Price”
is
defined
as
28
the
projected
cost
of
a
PBM’s
bid
to
provide
prescription
29
drug
benefits
to
allow
direct
comparison
of
the
comparably
30
calculated
costs
of
competing
PBMs’
proposals
over
the
duration
31
of
the
PBM’s
services
contract.
32
Consistent
with
Code
section
8A.311,
and
notwithstanding
33
any
other
law
to
the
contrary,
the
department
shall
enter
into
34
a
contract
for
the
services
of
a
PBM
for
the
administration
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of
benefits
of
self-funded
public
sector
health
plans.
1
“Self-funded
public
sector
health
plans”
is
defined
as
any
2
group
benefit
plan
under
Code
chapter
509A.
Prior
to
November
3
1,
2024,
DAS
shall
procure,
through
solicitation
of
proposals
4
from
qualified
professional
services
vendors,
a
technology
5
platform
with
capabilities
to
conducting
a
PBM
reverse
auction,
6
and
related
services
from
the
operator
of
the
technology
7
platform.
The
requirements
for
the
technology
platform
and
for
8
the
related
services
are
detailed
in
the
bill.
9
DAS
is
prohibited
from
awarding
a
contract
for
either
10
the
technology
platform
or
the
technology
operator
services
11
to
a
vendor
that
is
a
PBM
or
a
vendor
that
is
managed
12
by,
or
a
subsidiary
or
affiliate
of,
a
PBM.
The
vendor
13
awarded
the
contract
by
DAS
shall
not
outsource
any
part
14
of
the
PBM
reverse
auction
or
of
the
automated,
real-time,
15
electronic,
line-by-line,
claim-by-claim
review
of
invoiced
16
PBM
prescription
drug
claims.
With
technical
assistance
and
17
support
provided
by
the
technology
platform
operator,
DAS
shall
18
specify
the
terms
of
the
participant
bidding
agreement.
19
The
technology
platform
used
to
conduct
the
reverse
auction
20
shall
be
repurposed
over
the
duration
of
the
PBM’s
services
21
contract
as
an
automated
pharmacy
claims
adjudication
engine
22
to
perform
real-time,
electronic,
line-by-line,
claim-by-claim
23
review
of
100
percent
of
invoiced
PBM
drug
claims,
and
to
24
identify
all
deviations
from
the
specific
terms
of
the
PBM’s
25
services
contract.
26
DAS
is
required
to
reconcile
the
electronically
adjudicated
27
pharmacy
claims
with
PBM
invoices
on
a
monthly
or
quarterly
28
basis
to
ensure
that
state
payments
shall
not
exceed
the
terms
29
specified
in
any
PBM’s
services
contract.
If,
following
state
30
payment
to
the
PBM
on
the
basis
of
the
reconciliation,
the
31
PBM
asserts
that
DAS
has
paid
less
than
the
amount
owed,
the
32
PBM
may
seek
resolution
through
a
mutually
acceptable
dispute
33
resolution
process
as
agreed
to
in
the
terms
of
the
services
34
contract
between
the
parties.
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The
first
PBM
reverse
auction
shall
be
completed
and
the
1
PBM
services
contract
shall
be
awarded
to
the
winning
PBM
2
with
an
effective
date
beginning
July
1,
2024.
Subsequent
3
services
contracts
must
be
awarded
no
later
than
three
months
4
prior
to
termination
or
expiration
of
the
current
PBM’s
5
services
contract
for
a
covered
group,
such
as
the
state
6
employees
benefits
group,
that
includes
only
active
employees
7
and
dependents,
but
does
not
include
retiree
participants
in
8
a
Medicare
part
D
employer
group
waiver
program
(Medicare
9
employer
group)
pursuant
to
the
federal
Medicare
Prescription
10
Drug,
Improvement,
and
Modernization
Act
of
2003
(Medicare
11
Act).
If
an
eligible
covered
group
that
includes
retiree
12
participants
in
a
Medicare
employer
group
pursuant
to
the
13
Medicare
Act
opts
to
use
the
processes
and
procedures
under
the
14
bill,
the
relevant
PBM
reverse
auction
shall
be
completed
and
15
the
PBM
services
contract
shall
be
awarded
to
the
winning
PBM
16
no
later
than
six
months
prior
to
termination
or
expiration
17
of
the
current
PBM’s
services
contract
covering
the
Medicare
18
employer
group.
19
DAS
may
perform
a
market
check
for
providing
PBM
services
20
during
the
term
of
the
current
PBM’s
services
contract.
21
“Market
check”
is
defined
in
the
bill.
DAS
shall
implement
a
22
no-pay
option
that
obligates
the
winning
PBM,
rather
than
the
23
state,
to
pay
the
cost
of
the
technology
platform
and
related
24
technology
platform
operator
services
by
assessing
the
PBM
a
25
per-prescription
fee
as
detailed
in
the
bill.
26
The
bill
shall
apply
to
group
benefit
plans
under
Code
27
chapter
509A.
The
bill
shall
not
apply
to
nonprofit,
28
nongovernmental
health
maintenance
organizations
with
respect
29
to
managed
care
plans
that
provide
a
majority
of
covered
health
30
care
services
through
a
single
contracted
medical
group.
31
After
the
first
PBM
reverse
auction,
self-funded
private
32
sector
health
plans
with
substantial
participation
by
Iowa
33
employees
and
their
dependents
shall
have
the
option
to
34
participate
in
a
joint
purchasing
pool
with
state
employees
for
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subsequent
PBM
reverse
auctions.
Any
self-funded
public
sector
1
health
plans
or
self-funded
private
sector
health
plans
that
2
opt
to
participate
with
the
state
employees
group
benefits
plan
3
in
a
joint
PBM
reverse
auction
purchasing
pool
shall
retain
4
full
autonomy
as
detailed
in
the
bill.
5
DAS
may
elect
to
vacate
the
outcome
of
a
PBM
reverse
auction
6
if
the
lowest-cost
PBM
bid
is
not
less
than
the
projected
cost
7
trend
for
the
incumbent
PBM
contract
as
verified
by
DAS
or
by
8
a
consultant
retained
by
DAS.
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