HSB 685

The bill details the requirements that must be satisfied before a PBM places a particular drug on a maximum allowable cost list, or continues a particular drug on a maximum allowable cost list. “Maximum allowable cost list” (MAC list) is defined in the bill as a list of drugs or other methodology used by a PBM, directly or indirectly, setting the maximum allowable payment to a pharmacy for a generic drug, brand-name drug, biological product, or other prescription drug. A PBM cannot place a drug on the MAC list unless the PBM first complies with the requirements in the bill, including ensuring that the drug is available for purchase by each pharmacy in this state for a national or regional wholesaler licensed in this state. _____ A PBM must allow a pharmacy that is subject to a MAC list to have access to the list. The PBM is required to update a MAC list within seven calendar days of the date of an increase in the pharmacy acquisition cost, a change in methodology on which the MAC is based, or a change in any value of any variable involved in the methodology on which the MAC list is based. The PBM must provide a pharmacy subject to a MAC list with prompt notification of any updates to the MAC list. The bill provides that a PBM cannot reimburse a pharmacy in this state for a prescription drug in an amount less than the amount that the PBM reimburses a PBM affiliate for providing the same prescription drug. A pharmacy may decline to provide pharmacist services to a PBM or to a covered person if, as a result of a maximum allowable cost list, a pharmacy is to be paid less than that pharmacy’s pharmacy acquisition cost for the prescription drug. The bill requires a PBM to provide an appeal procedure to allow a pharmacy to challenge a maximum allowable cost list, and any reimbursement made under a maximum allowable cost list. The appeal procedure must include a dedicated telephone number, email address, and internet site for a pharmacy to submit appeals, and must include the ability to submit an appeal directly to the PBM or directly to the pharmacy service administration organization. Additional requirements for the appeals process, including the PBM’s obligations if an appeal is upheld or denied, are detailed in the bill. _____ requirements applicable to a pharmacy in this state. The bill also prohibits the PBM from charging or holding a pharmacy responsible for certain fees as detailed in the bill. A PBM or a health carrier also cannot directly or indirectly charge or hold a pharmacy responsible for a fee related to a claim in any of the circumstances detailed in the bill. A PBM is additionally prohibited from conducting spread pricing in this state. “Spread pricing” is defined as a model of prescription drug pricing in which a PBM charges a health benefit plan a contracted price for a prescription drug, and the contracted price for the prescription drug differs from the amount the PBM directly or indirectly pays a pharmacy for the prescription drug. The bill prohibits a PBM from terminating a contracted pharmacy for providing direct delivery or delivery by mail for prescriptions to covered persons. After the date of receipt of a clean claim for payment from a contracted pharmacy, the bill prohibits a PBM from retroactively reducing payment on the claim, either directly or indirectly, through an aggregated effective rate, direct or indirect remuneration, a quality assurance program, or any other means unless the claim is found not to be a clean claim during the course of a routine audit performed by the PBM. The bill provides that if a contracted pharmacy adjudicates a claim at the point of sale, the reimbursement amount provided to the pharmacy by the PBM is the final reimbursement amount. A PBM cannot recoup funds from a contracted pharmacy in connection with claims for which the pharmacy has already been paid except in circumstances outlined in the bill. The bill authorizes the commissioner of insurance to review and approve the compensation program of a PBM for a health carrier to ensure that the reimbursement for services provided by a contracted pharmacy is fair, reasonable, and appropriate to provide an adequate PBM network for the health carrier. _____ administer the provisions of the bill and to take any enforcement action under the commissioner’s authority to enforce compliance with the provisions of the bill. The bill provides that if any provision of the bill is held invalid, the invalidity shall not affect other provisions or applications of the bill which can be given effect without the invalid provisions.3, relating to current enforcement and rulemaking authority, and makes conforming changes throughout Code chapter 510B. The bill applies to a PBM providing pharmacy benefits management services in this state on or after the effective date of the bill.