H.B. 16 Enrolled

1

PHARMACY BENEFITS MANAGER ACT
2 2011 GENERAL SESSION
3 STATE OF UTAH
4 Chief Sponsor: Evan J. Vickers
5 Senate Sponsor: Curtis S. Bramble
6
7 LONG TITLE
8 General Description:
9 This bill enacts the Pharmacy Benefits Manager Act.
10 Highlighted Provisions:
11 This bill:
12 . defines terms;
13 . provides that when the Utah State Retirement Board (board) issues a request for
14 proposals (RFP) for a pharmacy benefits manager (PBM) to provide pharmacy
15 benefits management services for the Public Employees' Benefit and Insurance
16 Program (program), the RFP shall provide each responder with the option to
17 include, among the billing options proposed, a billing option that requires the PBM
18 to, on at least a monthly basis, submit to the board an invoice for all pharmacy
19 services paid by the PBM on behalf of the program since the last request for
20 payment or reimbursement; and
21 . provides that an invoice described in the preceding paragraph shall state, as a
22 separate item from any other amount:
23 . the total amount due to the pharmacy benefit manager for all pharmacy services
24 billed in the invoice; and
25 . the total amount paid by the pharmacy benefit manager for the same pharmacy
26 services for which payment is sought in that invoice.
27 Money Appropriated in this Bill:
28 None
29 Other Special Clauses:

30 None
31 Utah Code Sections Affected:
32 ENACTS:
33 49-20-501, Utah Code Annotated 1953
34 49-20-502, Utah Code Annotated 1953
35 49-20-503, Utah Code Annotated 1953
36
37 Be it enacted by the Legislature of the state of Utah:
38 Section 1. Section 49-20-501 is enacted to read:
39 Part 5. Pharmacy Benefits Manager Act
40 49-20-501. Title.
41 This part is known as the "Pharmacy Benefits Manager Act."
42 Section 2. Section 49-20-502 is enacted to read:
43 49-20-502. Definitions.
44 As used in this part:
45 (1) "Health benefit plan" means:
46 (a) a health benefit plan as defined in Section 31A-1-301 ; or
47 (b) a health, dental, medical, Medicare supplement, or conversion program offered
48 under Title 49, Chapter 20, Public Employees' Benefit and Insurance Program Act.
49 (2) "Pharmacist" is as defined in Section 58-17b-102 .
50 (3) "Pharmacy" is as defined in Section 58-17b-102 .
51 (4) "Pharmacy benefits management service" means any of the following services
52 provided to a health benefit plan, or to a participant of the health benefit plan:
53 (a) negotiating the amount to be paid by a health benefit plan for a prescription drug; or
54 (b) administering or managing prescription drug benefits provided by the health benefit
55 plan for the benefit of a participant of the health benefit plan, including:
56 (i) mail service pharmacy;
57 (ii) specialty pharmacy;

58 (iii) claims processing;
59 (iv) payment of a claim;
60 (v) retail network management;
61 (vi) clinical formulary development;
62 (vii) clinical formulary management services;
63 (viii) rebate contracting;
64 (ix) rebate administration;
65 (x) a participant compliance program;
66 (xi) a therapeutic intervention program;
67 (xii) a disease management program; or
68 (xiii) a service that is similar to, or related to, a service described in Subsection (4)(a)
69 or (4)(b)(i) through (xii).
70 (5) "Pharmacy benefits manager" means a person that provides a pharmacy benefits
71 management service to a health benefit plan.
72 (6) "Pharmacy service" means a product, good, or service provided by a pharmacy or
73 pharmacist to an individual.
74 Section 3. Section 49-20-503 is enacted to read:
75 49-20-503. Request for proposals for pharmacy benefits manager for Public
76 Employees' Benefit and Insurance Program.
77 (1) When the board issues a request for proposals for a pharmacy benefits manager to
78 provide pharmacy benefits management services for the program, the request for proposals
79 shall provide each responder with the option to include, among the billing options proposed, a
80 billing option that complies with the requirements described in this section.
81 (2) The billing option described in Subsection (1) shall require the pharmacy benefits
82 manager to, on at least a monthly basis, submit to the board an invoice for all pharmacy
83 services paid by the pharmacy benefits manager on behalf of the program since the last request
84 for payment or reimbursement.
85 (3) The invoice described in Subsection (2) shall state, as a separate item from any

86 other amount:
87 (a) the total amount due to the pharmacy benefits manager for all pharmacy services
88 billed in the invoice; and
89 (b) the total amount paid by the pharmacy benefits manager for the same pharmacy
90 services for which payment is sought in that invoice.