Source: http://wvlegislature.gov/Bill_Status/bills_text.cfm?billdoc=HB4543%20SUB.htm&yr=2020&sesstype=RS&i=4543
Timestamp: 2020-07-11 11:29:21
Document Index: 316757569

Matched Legal Cases: ['§33', '§33', '§33', '§5', '§5', '§33', '§33', '§5', '§33', '§33', '§33', '§33', '§33', '§5', '§33', '§33', '§33', '§33', '§33', '§5', '§33', '§33', '§33', '§33', '§33', '§5', '§33', '§33', '§33', '§33', '§33', '§16', '§33', '§30', '§30', '§5', '§33']

Committee Substitute House Bill 4543 History
By Delegates Hill, Pack, Fleischauer, Bates, Jennings, Summers, Atkinson, C. Thompson, Angelucci, Rohrbach, and Nelson
[Originating in the Committee on Health and Human Resources; January 22, 2020.]
A BILL to repeal an article designated §33-15C-1 of the Code of West Virginia, 1931, as amended; to amend said code by repealing one section , designated §33-16-16, of said code; to amend said code by adding thereto a new article designated, §33-53-1, of said code; and to amend and reenact two sections designated §5A-3-1a and §5-16-7, of said code, all relating to insurance coverage for diabetics.
(1) It is estimated that over 240,000 West Virginian’s are diagnosed and living with type 1 or type 2 diabetes and another 65,000 are undiagnosed;
(3) “Health plan” means any health benefit plan, as defined in §33-16-1a (h), that provides coverage for a prescription insulin drug.
(5) “Prescription insulin drug” means a prescription drug that contains insulin and is used to treat diabetes. “Prescription insulin drug” means a drug containing insulin and is used to control blood glucose level to treat diabetes.
(6) Pre-mixed insulin/GLP-1 RA products;
(d) Notwithstanding the provisions of §33-1-1 et seq. of this code, an insurer subject to §5-16-1 et seq., §33-15-1 et seq., §33-16-1 et seq., §33-24-1 et seq., §33-25-1 et seq., and §33-25A-1 of this code which issues or renews a health insurance policy on or after July 1, 2020, shall provide coverage for prescription insulin drugs pursuant to this section.
(e) Cost sharing for a 30-day supply of a covered prescription insulin drug shall not exceed $25 for a 30-day supply of a covered prescription insulin drug, regardless of the quantity or type of prescription insulin drug used to fill the covered person’s prescription needs.
(f) Nothing in this section prevents an insurer from reducing a covered person’s cost sharing to an amount less than the amount specified in subsection (e) of this section. by an amount greater than amount specified in this subsection.
(g) No contract between an insurer subject to §5-16-1 et seq., §33-15-1 et seq., §33-16-1 et seq., §33-24-1 et seq., §33-25-1 et seq., and §33-25A-1 or its pharmacy benefits manager and a pharmacy or its contracting agent shall contain a provision: (i) authorizing the insurer’s pharmacy benefits manager or the pharmacy to charge, (ii) requiring the pharmacy to collect, or (iii) requiring a covered person to make a cost-sharing payment for a covered prescription insulin drug in an amount that exceeds the amount of the cost-sharing payment for the covered prescription insulin drug established by the insurer pursuant to subsection (d). A drug manufacturer, drug wholesaler, or pharmacy benefit manager may not pass through the costs of the prescription insulin drug to the pharmacist or pharmacy. The commissioner may use any of the commissioner’s enforcement powers to obtain an insurer’s or pharmaceutical benefit manager’s compliance with this section.
(h) An insurer subject to §5-16-1 et seq., §33-15-1 et seq., §33-16-1 et seq., §33-24-1 et seq., §33-25-1 et seq., and §33-25A-1 shall provide coverage for the following equipment and supplies for the treatment and/or management of diabetes for both insulin dependent and noninsulin dependent persons with diabetes and those with gestational diabetes: blood glucose monitors, monitor supplies, insulin, injection aids, syringes, insulin infusion devices, pharmacological agents for controlling blood sugar and orthotics.
(i) An insurer subject to §5-16-1 et seq., §33-15-1 et seq., §33-16-1 et seq., §33-24-1 et seq., §33-25-1 et seq., and §33-25A-1 shall include coverage for diabetes self-management education to ensure that persons with diabetes are educated as to the proper self-management and treatment of their diabetes, including information on proper diets.
(j) All health care plans must offer an appeals process for persons who are not able to take one or more of the offered prescription insulin drugs noted in subsection (c). The appeals process shall be provided to covered persons in writing and afford covered persons and their health care providers a meaningful opportunity to participate with covered persons healthcare providers.
(k) Diabetes self-management education shall be provided by a health care practitioner who has been appropriately trained. The Secretary of the Department of Health and Human Services shall promulgate legislative rules to implement training requirements and procedures necessary to fulfill provisions of this subsection: Provided, That any rules promulgated by the Secretary shall be done after consultation with the Coalition for Diabetes Management, as established in §16-5Z-1, et seq. of this code.
(i) The education may be provided by a health care practitioner as part of an office visit for diabetes diagnosis or treatment, or by a licensed pharmacist for instructing and monitoring a patient regarding the proper use of covered equipment, supplies and medications, or by a certified diabetes educator, or registered dietitian.
CHAPTER 5A. DEPARTMENT OF ADMINSTRATION.
(a) In addition to other provisions of this article, the division is authorized, on behalf of the Public Employees Insurance Agency, the schools of medicine of the state colleges and universities, the department division of vocational rehabilitation and the Department of Health and Human Resources, to negotiate and enter into agreements directly with manufacturers and distributors whose prescription drug products are sold in the state for sole-source and multiple-source drugs to be paid for under state program for eligible recipients. Such agreements shall provide for a rebate of a negotiated percentage of the total product cost to be paid by the manufacturer or distributor of the specific product. Each agency is authorized to establish, either singularly or together with other agencies, a drug formulary.
If there has been a failure to negotiate or renew a rebate agreement for a specific prescription drug product, the pharmaceutical manufacturer of that product shall disclose to the division its most favorable pricing arrangements available to state and nonstate government purchasers. If the division determines that the product needs to be included in the drug formulary, with the approval of the agency the division shall establish the amount to be reimbursed for the product based upon the price information provided by the manufacturer. The determination as to whether a product should be included in the drug formulary is based on the product’s efficiency, cost, medical necessity, and safety. Any rebate returns, as a result of the provisions of this section regarding prescription drugs, shall be deposited in the general revenue fund.
(b) In the event any manufacturer of a prescription insulin drug included in §33-53-1 of this code certifies that the listed price of the prescription insulin drug is less than or equal to the list price which was publicly available for the same prescription insulin drug on July 1, 2006, the Purchasing Division of the Department of Administration purchasing division may negotiate an agreement on behalf of the Public Employees Insurance Agency, the schools of medicine of the state colleges and universities, the department of vocational rehabilitation and the Department of Health and Human Resources, to purchase the prescription insulin drug from the manufacturer at or below its July 1, 2006 list price, without negotiating, including or demanding any rebate. If a prescription insulin drug price is less than or equal to that drug’s certified list price as of July 1, 2006, the division is hereby prohibited from negotiating any agreement for a rebate of a negotiated percentage of the total cost to be paid to the manufacturer or distributor of the specific prescription insulin drug; and the Public Employees Insurance Agency, the schools of medicine of the state colleges and universities, the department of vocational rehabilitation and the Department of Health and Human Resources are prohibited from any rebate from the manufacturer or distributor of the drug.
(c) It is expressly recognized that no other entity may interfere with the discretion and judgment given to the single state agency that administers the state’s Medicaid program. Therefore, the Department of Health and Human Resources is authorized to negotiate rebates as provided for this section.
(C) The agency shall not discriminate between medical-surgical benefits and mental health benefits in the administration of its plan. With regard to both medical-surgical and mental health benefits, it may make determinations of medical necessity and appropriateness and it may use recognized healthcare quality and cost management tools including, but not limited to, limitations on inpatient and outpatient benefits, utilization review, implementation of cost-containment measures, preauthorization for certain treatments, setting coverage levels, setting maximum number of visits within certain time periods, using capitated benefit arrangements, using fee-for-service arrangements, using third-party administrators, using provider networks, and using patient cost-sharing in the form of copayments, deductibles, and coinsurance.
(10) (A) A policy, plan, or contract that is issued or renewed on or after January 1, 2019, and that is subject to this section, shall provide coverage, through the age of 20, for amino acid-based formula for the treatment of severe protein-allergic conditions or impaired absorption of nutrients caused by disorders affecting the absorptive surface, function, length, and motility of the gastrointestinal tract. This includes the following conditions, if diagnosed as related to the disorder by a physician licensed to practice in this state pursuant to either §30-3-1 et seq., or §30-14-1 et seq. of this code:
(i) Immunoglobulin E and Non-immunoglobulin E-medicated allergies to multiple food proteins;
(11) A policy, plan, or contract that is issued or renewed on or after July 1, 2020 shall provide coverage for prescription insulin drugs pursuant to this section.
(A) For the purposes of this subdivision, “prescription insulin drug” means a prescription drug that contains insulin, and is used to treat diabetes, and a drug containing insulin and is used to control blood glucose level to treat diabetes, includes at least one type of insulin in all of the following categories:
(B) Cost sharing for a 30-day supply of a covered prescription insulin drug shall not exceed $25 for a 30-day supply of a covered prescription insulin drug, used to fill the covered person’s prescription needs.
(C) Nothing in this section prevents the agency from reducing a covered person’s cost sharing by an amount greater than the amount specified in this subsection.
(D) No contract between the agency or its pharmacy benefits manager and a pharmacy or its contracting agent shall contain a provision (i) authorizing the agency’s pharmacy benefits manager or the pharmacy to charge, (ii) requiring the pharmacy to collect, or (iii) requiring a covered person to make a cost-sharing payment for a covered prescription insulin drug in an amount that exceeds the amount of the cost-sharing payment for the covered prescription insulin drug established by the agency as provided in §5-16-7(a)(11)(B) of this code.
(E) The agency shall provide coverage for the following equipment and supplies for the treatment or management of diabetes for both insulin dependent and noninsulin dependent persons with diabetes and those with gestational diabetes: Blood glucose monitors, monitor supplies, insulin, injection aids, syringes, insulin infusion devices, pharmacological agents for controlling blood sugar and orthotics.
(F) The agency shall provide coverage for diabetes self-management education to ensure that persons with diabetes are educated as to the proper self-management and treatment of their diabetes, including information on proper diets. Coverage for self-management education and education relating to diet shall be provided by a health care practitioner who has been appropriately trained as provided in §33-53-1(k) of this code.
(i) Visits medically necessary upon the diagnosis of diabetes;
(ii) Visits under circumstances where a health care practitioner identifies or diagnoses a significant change in the patient’s symptoms or conditions that necessitates changes in a patient’s self-management; and
(iii) Where a new medication or therapeutic process relating to the person’s treatment or management of diabetes has been identified as medically necessary by a health care practitioner: Provided, That coverage for reeducation or refresher education shall be limited to $100 annually.
(G) The education may be provided by a health care practitioner as part of an office visit for diabetes diagnosis or treatment, or by a licensed pharmacist for instructing and monitoring a patient regarding the proper use of covered equipment, supplies and medications, or by a certified diabetes educator, or registered dietitian.
NOTE: The purpose of this bill is to cap costs for insulin and provide certain coverage mandates.