The state employees’ prescription drug program is established. This program shall be administered by the Department of Management Services, according to the terms and conditions of the plan as established by the relevant provisions of the annual General Appropriations Act and implementing legislation, subject to the following conditions:(1) The department shall allow prescriptions written by health care providers under the plan to be filled by any licensed pharmacy and reimbursed pursuant to subsection (2). This section may not be construed as prohibiting a mail order prescription drug program distinct from the service provided by retail pharmacies.
(2) In providing for reimbursement of pharmacies for prescription drugs and supplies dispensed to members of the state group health insurance plan and their dependents under the state employees’ prescription drug program:(a) Retail, mail order, and specialty pharmacies participating in the program must be reimbursed as established by contract and according to the terms and conditions of the plan.
(b) There is a 30-day supply limit for retail pharmacy fills, a 90-day supply limit for mail order fills, and a 90-day supply limit for maintenance drug fills by retail pharmacies. This paragraph may not be construed to prohibit fills at any amount less than the applicable supply limit.
(c) The pharmacy dispensing fee shall be negotiated by the department.
(d) The department shall establish the reimbursement schedule for prescription drugs and supplies dispensed under the program. Reimbursement rates for a prescription drug or supply must be based on the cost of the generic equivalent drug or supply if a generic equivalent exists, unless the physician, advanced practice registered nurse, or physician assistant prescribing the drug or supply clearly states on the prescription that the brand name drug or supply is medically necessary or that the drug or supply is included on the formulary of drugs and supplies that may not be interchanged as provided in chapter 465, in which case reimbursement must be based on the cost of the brand name drug or supply as specified in the reimbursement schedule adopted by the department.
(3) The department shall maintain the generic, preferred brand name, and the nonpreferred brand name lists of drugs and supplies to be used in the administration of the state employees’ prescription drug program.
(4) The department shall maintain a list of maintenance drugs and supplies.(a) Preferred provider organization health plan members may have prescriptions for maintenance drugs and supplies filled up to three times as a supply for up to 30 days through a retail pharmacy; thereafter, prescriptions for the same maintenance drug or supply must be filled for up to 90 days either through the department’s contracted mail order pharmacy or through a retail pharmacy.
(b) Health maintenance organization health plan members may have prescriptions for maintenance drugs and supplies filled for up to 90 days either through a mail order pharmacy or through a retail pharmacy.
(5) Copayments made by health plan members for a supply for up to 90 days through a retail pharmacy shall be the same as copayments made for a similar supply through the department’s contracted mail order pharmacy.
(6) The department shall conduct a prescription utilization review program. In order to participate in the state employees’ prescription drug program, retail pharmacies dispensing prescription drugs and supplies to members of the state group health insurance plan or their covered dependents, or to subscribers or covered dependents of a health maintenance organization plan under the state group insurance program, shall make their records available for this review.
(7) Participating pharmacies must use a point-of-sale device or an online computer system to verify a participant’s eligibility for coverage. The state is not liable for reimbursement of a participating pharmacy for dispensing prescription drugs and supplies to any person whose current eligibility for coverage has not been verified by the state’s contracted administrator or by the department.
(8)(a) Effective July 1, 2017, for the State Group Health Insurance Standard Plan, copayments must be made as follows:1. For a supply for up to 30 days from a retail pharmacy:a. For generic drug..........$7.
b. For preferred brand name drug..........$30.
c. For nonpreferred brand name drug..........$50.
2. For a supply for up to 90 days from a mail order pharmacy or a retail pharmacy:a. For generic drug..........$14.
b. For preferred brand name drug..........$60.
c. For nonpreferred brand name drug..........$100.
(b) Effective July 1, 2017, for the State Group Health Insurance High Deductible Plan, coinsurance must be paid as follows:1. For a supply for up to 30 days from a retail pharmacy:a. For generic drug..........30%.
b. For preferred brand name drug..........30%.
c. For nonpreferred brand name drug..........50%.
2. For a supply for up to 90 days from a mail order pharmacy or a retail pharmacy:a. For generic drug..........30%.
b. For preferred brand name drug..........30%.
c. For nonpreferred brand name drug..........50%.
(9)(a) Beginning with the 2020 plan year, the department must implement formulary management for prescription drugs and supplies. Such management practices must require prescription drugs to be subject to formulary inclusion or exclusion but may not restrict access to the most clinically appropriate, clinically effective, and lowest net-cost prescription drugs and supplies. Drugs excluded from the formulary must be available for inclusion if a physician, advanced practice registered nurse, or physician assistant prescribing a pharmaceutical clearly states on the prescription that the excluded drug is medically necessary. Prescription drugs and supplies first made available in the marketplace after January 1, 2020, may not be covered by the prescription drug program until specifically included in the list of covered prescription drugs and supplies.
(b) No later than October 1, 2019, and by each October 1 thereafter, the department must submit to the Governor, the President of the Senate, and the Speaker of the House of Representatives the list of prescription drugs and supplies that will be excluded from program coverage for the next plan year. If the department proposes to exclude prescription drugs and supplies after the plan year has commenced, the department must provide notice to the Governor, the President of the Senate, and the Speaker of the House of Representatives of such exclusions at least 60 days before implementation of such exclusions.
(10) In addition to the comprehensive package of health insurance and other benefits required or authorized to be included in the state group insurance program, the program must provide coverage for medically necessary prescription and nonprescription enteral formulas and amino-acid-based elemental formulas for home use, regardless of the method of delivery or intake, which are ordered or prescribed by a physician. As used in this subsection, the term “medically necessary” means the formula to be covered represents the only medically appropriate source of nutrition for a patient. Such coverage may not exceed an amount of $20,000 annually for any insured individual.
