1.This Act may be cited as the
Medicaid Prescription Drug Rebate
Equalization Act of 2009
.
2.Extension of
prescription drug discounts to enrollees of Medicaid managed care
organizations
(a)Section 1903(m)(2)(A) of the Social Security Act (42
U.S.C. 1396b(m)(2)(A)) is amended—
(1)in clause (xi), by
striking and
at the end;
(2)in clause (xii),
by striking the period at the end and inserting ; and
;
and
(3)by adding at the
end the following:
(xiii)such contract
provides that (I) payment for covered outpatient drugs dispensed to individuals
eligible for medical assistance who are enrolled with the entity shall be
subject to the same rebate required by the agreement entered into under section
1927 as the State is subject to, and (II) capitation rates paid to the entity
shall be based on actual cost experience related to rebates and subject to the
Federal regulations requiring actuarially sound
rates.
.
(b)Section 1927 of the Social Security Act (42 U.S.C.
1396r–8) is amended—
(1)in
subsection (d)—
(A)in paragraph (1),
by adding at the end the following:
(C)Notwithstanding
subparagraphs (A) and (B)—
(i)a
Medicaid managed care organization with a contract under section 1903(m) may
exclude or otherwise restrict coverage of a covered outpatient drug on the
basis of policies or practices of the organization, such as those affecting
utilization management, formulary adherence, and cost sharing or dispute
resolution, in lieu of any State policies or practices relating to the
exclusion or restriction of coverage of such drugs, provided, however, that any
such exclusions and restrictions of coverage shall be subject to any
contractual requirements and oversight by the State. As contained in the
Medicaid managed care organization’s contract with the State, the State shall
maintain approval authority over the formulary used by the Medicaid managed
care organization; and
(ii)nothing in this
section or paragraph (2)(A)(xiii) of section 1903(m) shall be construed as
requiring a Medicaid managed care organization with a contract under such
section to maintain the same such policies and practices as those established
by the State for purposes of individuals who receive medical assistance for
covered outpatient drugs on a fee-for-service
basis.
;
and
(B)in paragraph (4),
by inserting after subparagraph (E) the following:
(F)Notwithstanding
the preceding subparagraphs of this paragraph, any formulary established by a
Medicaid managed care organization with a contract under section 1903(m) may be
based on the positive inclusion of drugs selected by a formulary committee
consisting of physicians, pharmacists, and other individuals with appropriate
clinical experience as long as drugs excluded from the formulary are available
through prior authorization, as described in paragraph
(5).
;
and
(2)in subsection (j),
by striking paragraph (1) and inserting the following:
(1)Covered outpatients
drugs are not subject to the requirements of this section if such drugs
are—
(A)dispensed by
health maintenance organizations, including Medicaid managed care organizations
that contract under section 1903(m); and
(B)subject to
discounts under section 340B of the Public Health Service
Act.
.
(c)On a quarterly basis, the States shall
report to the Department of Health and Human Services the total amount of
rebates in dollars and volume received from pharmacy manufacturers for drugs
provided to individuals enrolled with Medicaid managed care organizations that
contract under section 1903(m) of the Social Security Act (42 U.S.C. 1396b(m))
as a result of this section for both brand-name and generic drugs. This report
shall be made publicly available.
(d)The amendments made by this section take effect on the date
of the enactment of this Act and apply to rebate agreements entered into or
renewed under section 1927 of the Social Security Act (42 U.S.C. 1396r–8) on or
after such date.