BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 1301
AUTHOR: Hernandez
AMENDED: March 29, 2012
HEARING DATE: April 11, 2012
CONSULTANT: Moreno
SUBJECT : Prescription drugs: 90-day supply.
SUMMARY : Permits a pharmacist to dispense up to a 90-day supply
of a drug, other than a controlled substance, pursuant to a
prescription that specifies the initial dispensing of a lesser
amount followed by periodic refills of that amount if certain
requirements are met.
Existing law:
1.Provides for the practice of pharmacy and the licensing and
regulation of pharmacies and pharmacists by the Board of
Pharmacy within the Department of Consumer Affairs.
2.Specifies certain requirements regarding the dispensing and
furnishing of dangerous drugs and devices, and prohibits a
person from furnishing any dangerous drug or device except
upon the prescription of a physician, dentist, podiatrist,
optometrist, or veterinarian.
3.Prohibits a prescription for any dangerous drug or dangerous
device from being refilled except upon authorization of the
prescriber, as specified.
4.Permits a prescription for a dangerous drug or dangerous
device to be refilled without the prescriber's authorization
if the prescriber is unavailable to authorize the refill and
if, in the pharmacist's professional judgment, failure to
refill the prescription might interrupt the patient's ongoing
care and have a significant adverse effect on the patient's
well-being. Permits the prescription to be filled only after
making every reasonable effort to contact the prescriber.
Requires the pharmacist to inform the patient and the provider
that the prescription was refilled under this circumstance.
This bill:
1.Permits a pharmacist to dispense up to a 90-day supply of a
dangerous drug other than a controlled substance pursuant to a
Continued---
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valid prescription that specifies the initial dispensing of a
lesser amount followed by periodic refills of that amount if :
a. The total quantity of dosage units dispensed does
not exceed the total quantity of dosage units authorized
by the prescriber on the prescription, including refills;
b. The prescriber has not specified on the prescription
that dispensing the prescription in an initial amount
followed by periodic refills is medically necessary; and
c. The pharmacist is exercising his or her professional
judgment.
2.Prohibits anything in this bill from being construed to
require a health care service plan, health insurer, workers'
compensation insurance plan, pharmacy benefits manager (PBM),
or any other person or entity, including, but not limited to,
a state program or state employer, to provide coverage for a
dangerous drug in a manner inconsistent with a beneficiary's
plan benefit.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1.Author's statement. According to the author, the cost of a
filled prescription is based on the "Product Cost + Dispensing
Cost." For each trip to the pharmacy, the patient must not
only pay for the additional product but also the other costs
that are associated with dispensing that drug. The author
states that paying for the professional services of a
pharmacist and pharmacy technicians only once, rather than
three times, allows the payer and patient to accrue
significant savings. A patient that visits the pharmacy every
month to refill a maintenance prescription creates higher
health care costs because repeat visits cost more than a
single visit. Additionally, patient non-compliance with their
prescription drugs drives up health care costs. Failure to
take prescribed medications can lead to deterioration of the
patient's health, which, in turn, leads to higher-cost
medications or medical interventions. By 2014, there will be 6
million more Californians insured. As more Californians
become insured, we must ensure patients have access to care
and reduce overall health care costs for chronic conditions.
SB 1301 is a simple effort toward increasing consumer access
to health care and local pharmacists.
2.PBMs and mail-order pharmacies. Increasing numbers of
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employers, labor unions, and managed care companies
(collectively, "plan sponsors") that offer prescription drug
insurance coverage often hire PBMs to manage these benefits.
According to a 2005 Federal Trade Commission study of PBMs,
they use mail-order pharmacies to manage prescription drug
costs. Many PBMs also own their own mail-order pharmacies.
Plan sponsors often encourage patients with chronic conditions
who require repeated refills to seek the discounts that 90-day
prescriptions and high-volume mail-order pharmacies can offer.
As medication prices continue to rise faster than inflation,
one method to control pharmacy benefit costs is for health
plans and PBMs to offer 90-day supply coverage which reduces
costs via a decrease in dispensing fees and potentially
increases adherence, according to an article in the American
Journal of Health-System Pharmacy titled "Ninety-day versus
thirty-day drug dispensing systems." The authors concluded
that dispensing less expensive drugs for 90 days rather than
30 days to patients with chronic diseases would result in
significant cost savings without compromising safety, despite
the possibility of increased waste when drugs are
discontinued.
3.Other states. According to the sponsor of this bill, the
California Retailers Association (CRA), 20 states have varying
statutes that in some way permit 90-day dispensing (Alaska,
Arizona, Colorado, Florida, Hawaii, Idaho, Illinois, Kentucky,
Main, Michigan, Montana, Nebraska, New York, North Carolina,
Rhode Island, South Carolina, South Dakota, Texas, Vermont,
and Wyoming). For example, New York mandates that if a health
plan or insurer offers a 90-day supply through a mail-order
pharmacy, the enrollee can obtain the same supply at a retail
pharmacy, provided the pharmacy accepts the same contractual
terms and conditions as the mail-order pharmacy. Indiana has
legislation pending on the Governor's desk that permits 90
days' worth of medication upon the request of the patient if
the patient has completed an initial 30-day supply of the
drug. However, a pharmacist is required to notify the
prescriber of the change in the quantity filled and comply
with state and federal laws and regulations concerning the
dispensing limitations concerning a prescription drug.
4.Double referral. This bill is double referred. Should it
pass out of this committee, it will be referred to the Senate
Committee on Business, Professions and Economic Development.
5.Support. According to CRA and the National Association of
Chain Drug Stores (NACDS), a single chain drug store makes
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approximately 4.5 million calls a month to get authorization
to dispense a prescription refill in excess of a 30-day
supply. CRA and NACDS state that because physicians are
typically busy and unable to take these calls, consumers end
up either having to wait for authorization or they end up
settling for the 30-day supply, leaving before the physician
calls back. CRA, NACDS, and Aging Services of California
(ASC) write that not only are these calls burdensome to the
physicians and pharmacists, the patient is ultimately
inconvenienced and will need to return to the pharmacy two
additional times and pay two additional co-payments that he or
she would have saved under this proposal. ASC further states
that by allowing a 90-day supply, this bill will make it
easier for patients to adhere to their treatment, live
healthier lives and lower costs throughout the health care
system. The County of Los Angeles contends that this bill
will increase access to needed medications and improve the
health of many County residents with chronic health conditions
that are easily controlled with prescribed medications. BIOCOM
writes that this bill will likely reduce missed dosages and
increase dosage compliance by patients by allowing them to
have to refill prescriptions less often, and could reduce
total prescription costs by reducing the number of pharmacy
visits.
6.Support if amended. The California Medical Association (CMA)
is concerned that this bill could weaken the physician's
ability to monitor a patient's progress and, if necessary,
modify the patient's drug regimen. By eliminating refills,
physicians would lose a valuable tool often used to monitor
the progress of their patient's treatment. CMA additionally
states that, while this bill does not apply to controlled
substances, there are still other dangerous drugs that aren't
on the controlled substance list that can still be very
hazardous to the patient if dispensed improperly and misused.
CMA is asking for amendments to ensure physician autonomy over
the amount of drugs prescribed.
7.Oppose unless amended. The California Psychiatric Association
(CPA) writes that from a psychiatric physician standpoint,
many psychiatric medications are toxic or lethal, and that
potential is increased significantly when a patient presents
with suicidal ideation. The CPA would prefer that the primary
thrust of this bill provide that physicians have the ability
to "opt in" to this measure, and failing that, exempting
psychotropic medications, prescribed by any physician of any
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specialty or subspecialty, from the provisions of this bill.
8.Amendments. The author intends to amend the bill as follows:
On page 2, delete lines 3 through 18 and insert:
4064.5 (a) A pharmacist may dispense not more than a ninety
(90) day supply of medication pursuant to a valid
prescription that specifies the initial dispensing of a
lesser amount followed by periodic refills of that amount
if the patient has completed an initial thirty (30) day
supply of the drug therapy and all of the following
requirements are satisfied:
(1) The total quantity of dosage units dispensed
does not exceed the total quantity of dosage units
authorized by the prescriber on the prescription,
including refills.
(2) The prescriber has not specified on the
prescription that dispensing the prescription in an
initial amount followed by periodic refills is
medically necessary.
(3) The pharmacist is exercising his or her
professional judgment.
(b) A pharmacist dispensing pursuant to this section shall
notify the prescriber of the change in the quantity filled.
(c) This section does not apply to psychotropic medication,
as defined in Welfare and Institutions Code Section 369.5
(d).
SUPPORT AND OPPOSITION :
Support: California Retailers Association (sponsor)
Aging Services of California
BIOCOM
California Healthcare Institute
Los Angeles County Board of Supervisors
National Association of Chain Drug Stores
Three individuals
Oppose: California Psychiatric Association (unless amended)
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