| Summary |
Under current law, pharmacy benefit managers (PBMs) are
required to perform certain acts and are prohibited from engaging in
certain acts. Specifically, PBMs are prohibited from:
•
Requiring patients to obtain their prescription drugs
through mail order;
•
Charging pharmacies fees to adjudicate claims;
•
Requiring pharmacies to obtain accreditations or
certifications that are different than what the PBM requires
of its affiliated pharmacies;
•
Retroactively reducing a payment made to a pharmacy on
a drug claim after the point of sale or reimbursing a
pharmacy in an amount that is less than the amount
reimbursed to its own affiliated pharmacy for the same
pharmacy service;
•
Modifying the prescription drug formulary under a health
benefit plan during the plan year;
•
With regard to audits, using specified techniques in
calculating a recoupment or penalty, subjecting a pharmacy
to recoupment when a clerical error is discovered, and
requiring pharmacies to be audited more than once a year;
•
Prohibiting a pharmacy or pharmacist from, or penalizing
a pharmacy or pharmacist for, providing information to
patients about more affordable, therapeutically equivalent
alternatives to a prescribed drug; or
•
Requiring a pharmacy or pharmacist to charge or collect a
copayment from an insured patient that exceeds the total
charge submitted by the pharmacy for the prescription
drug.
Additionally, PBMs are required to:
•
Provide pharmacies 7 days' written notice before an audit,
conduct an audit by or in consultation with a pharmacist,
allow the pharmacy to supplement claims documentation,
and establish an appeals process;
•
Provide an insured individual, the insured's health-care
provider, or a third party acting on behalf of the insured or
provider with up-to-date and real-time cost, benefit, and
coverage information under the terms of the insured's
health benefit plan; and
•
Provide contracted pharmacies with the list of sources the
PBM used in determining maximum allowable cost pricing,
update the information every 7 days, allow pharmacies the
ability to readily review the information, follow specified
requirements when placing a drug on the maximum
allowable cost list, and establish an appeals process to
resolve disputes.
The bill specifies that the commissioner of insurance
(commissioner) has the power to enforce these prohibitions and
requirements and impose penalties on PBMs for failing to comply with
these prohibitions and requirements.
Additionally, the bill requires:
•
PBMs to register with and pay a registration fee to the
commissioner; and
•
Health insurers to pay a fee when filing with the
commissioner their list of PBMs they use for prescription
drug benefits administration.
The fees imposed under the bill are to be used to fund the costs of
the division of insurance in enforcing requirements and prohibitions on
PBMs.
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