Relating to pharmacy benefits managers, pharmacies, prescription drugs, and pharmacy services administrative organizations, and including applicability provisions

A PBM shall not deny a pharmacy the right to participate as a contract provider under a plan if the pharmacy agrees to the terms and requirements of the plan and the terms of reimbursement. A PBM shall not impose upon a pharmacy, as a condition of participation in a network, any course of study, accreditation, certification, or credentialing different than those imposed by state requirements and the rules adopted by the board of pharmacy. A PBM shall not unreasonably designate a prescription drug (prescription) as a specialty drug to prevent a person from accessing the prescription, or to limit a person’s access to the prescription from a pharmacy that is within the person’s plan’s network. A person or pharmacy harmed by such a violation may file a complaint with the commissioner of insurance (commissioner). A PBM shall not require a person, as a condition of payment or reimbursement, to purchase pharmacy services exclusively through a mail order pharmacy. A PBM shall not impose upon a person any payment or condition for purchasing pharmacy services that is more costly or restrictive than if such services were purchased from a mail order pharmacy, or any other pharmacy. If a third-party payor (payor) providing reimbursement to persons for prescriptions restricts pharmacy participation, the payor shall notify, in writing, all pharmacies within the geographical coverage area of the plan, and offer the pharmacies the opportunity to participate in the plan at least days prior to the effective date of the restriction. All pharmacies in the geographical coverage area are eligible to participate under identical reimbursement terms. The payor shall inform persons of the names and locations of all pharmacies participating in the plan. A participating pharmacy shall be entitled to announce the pharmacy’s participation to the pharmacy’s customers. The commissioner shall not certify any PBM or license an insurance producer not in compliance with the bill. A PBM shall not impose different cost-sharing or additional fees on a person based on the pharmacy at which the person fills a prescription order. A person’s cost-sharing for a prescription shall be calculated at the point of sale based on a price that is reduced by an amount equal to at least 100 percent of all rebates that have been received, or will be received, by the health carrier or a PBM in connection with the dispensing or administration of the prescription. Any additional rebate in excess of the required cost-sharing shall be passed on to the plan for the purpose of reducing premiums. A PBM shall include any amount paid by a person, or on behalf of a person, when calculating the person’s total contribution toward the person’s cost-sharing. Any amount paid by a person for a prescription shall be applied to any deductible imposed on the person by the person’s plan in accordance with the coverage documents. The bill prohibits a PBM from reimbursing a pharmacy in an amount less than the national average drug acquisition cost or, if unavailable, the wholesale acquisition cost, for a prescription on the date that the prescription is administered or dispensed.60. A PBM shall submit a quarterly report to the commissioner that contains the information detailed in the bill, and publish such report on the PBM’s public internet site as described in the bill. The bill requires all contracts executed, amended, adjusted, or renewed on or after July 1, 2025, that are applicable to prescription benefits on or after January 1, 2026, between a PBM and a payor, or between a person and a payor, to use a pass-through pricing model with an exception as detailed in the bill, and to ensure that payments received by a PBM for providing services to a payor or a pharmacy are used or distributed pursuant to the PBM’s contract with the payor or with the pharmacy, or as otherwise required by law. “Pass-through pricing” and “spread pricing” are defined in the bill. The bill requires a PBM to provide a process for pharmacies to appeal a reimbursement rate for a specific prescription. The appeal process is detailed in the bill. If a PBM denies a pharmacy’s appeal, the pharmacy may submit the denial to the commissioner for examination. The bill applies to pharmacy benefits managers that manage a prescription drug benefit in the state on or after July 1, 2025.