Pharmacy Benefits Carrier And Pharmacy Benefit Manager Requirements

The bill imposes requirements regarding the administration of prescription drug benefits under health benefit plans as follows:

• Requires a health insurer to submit to the commissioner of insurance a list of pharmacy benefit managers (PBMs) the health insurer uses to manage or administer prescription drug benefits under its health benefit plans offered in this state;
• Requires health insurers and PBMs to submit their programs for compensating pharmacies and pharmacists and their prescription drug formularies under their prescription drug benefits plans, and the commissioner is authorized to review the compensation programs to ensure they are fair and reasonable to provide an adequate network of pharmacies and pharmacists under their prescription drug benefits plans;
• Requires a PBM to also report to the commissioner the amount the PBM expects to be reimbursed from health insurers for pharmacist services;
• Prohibits health insurers and PBMs from:
• Causing or knowingly permitting the use of any untrue, deceptive, or misleading advertisement, promotion, solicitation, representation, proposal, or offer;
• Charging a pharmacy or pharmacist a fee for adjudicating a claim;
• Requiring stricter pharmacy accreditation standards or certification requirements than the standards or requirements that are required by the state board of pharmacy;
• Reimbursing an independent pharmacy or pharmacist an amount that is less than the amount the health insurer or PBM reimburses an affiliated pharmacy or pharmacist; and
• Modifying their prescription drug formulary at any time during the benefit year.
• If a pharmacy or pharmacist is eliminated from a health care provider or PBM network, specifies that the health insurer or PBM is not relieved of any obligation to pay for pharmacist services properly rendered before elimination from the network; and
• Requires health insurers and PBMs to report specified claims data to the commissioner and the all-payer health claims database.

The commissioner is authorized to adopt rules to implement the bill and to enforce the bill using all powers granted the commissioner under the insurance laws of this state. A health insurer is:

• Responsible for complying with the bill and ensuring any PBM the health insurer uses is complying with the bill; and
• Liable for failure of the health insurer or PBM to comply.
  (Note: This summary applies to this bill as introduced.)