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Pharmacy Benefit Manager And Insurer Requirements

Concerning requirements regarding the administration of prescription drug benefits under health benefit plans.
2021 Regular Session
Health Care & Health Insurance
Bill Summary

The bill precludes a health insurer, a pharmacy benefit manager (PBM), or an entity acting for a health insurer or PBM to conduct on-site audits of pharmacies within 12 months after a prior on-site audit except in specified circumstances.

Additionally, the bill enacts the "Pharmacy Fairness Act" (act), which imposes requirements regarding contracts between PBMs and pharmacies as follows:

  • Requires a health insurer to submit to the commissioner of insurance (commissioner) a list of PBMs the health insurer uses to manage or administer prescription drug benefits under its health benefit plans offered in this state;
  • Prohibits PBMs from:
  • Restricting a covered person's access to prescription drug benefits at an in-network retail pharmacy, except as permitted in limited circumstances;
  • Charging a pharmacy or pharmacist a fee for adjudicating a claim, other than a one-time fee of not more than the lesser of 25% of the pharmacy dispensing fee or 25 cents for receipt and processing of the same pharmacy claim;
  • Requiring stricter pharmacy accreditation standards or certification requirements than the standards or requirements that are applicable to similarly situated PBM-affiliated pharmacies within the same PBM network; or
  • Refusing to designate a pharmacy located in a county with a population of 20,000 or fewer as a preferred pharmacy under the health benefit plan.

A PBM that administers the drug assistance program operated by the department of public health and environment is exempt from the requirements and prohibitions of the act with regard to the PBM's administration of that program only.

The bill also:

  • Requires a health insurer or PBM to respond in real time to a request from an insured, the insured's health care provider, or a third party acting on behalf of the insured or provider for data regarding the cost, benefits, and coverage under the insured's health benefit plan for a particular drug; and
  • Requires a health insurer or PBM that removes a prescription drug from the prescription drug formulary or moves a prescription drug to a higher cost tier on the formulary during the benefit year to notify a covered person that is prescribed that drug at least 30 days before the action and allow the covered person to continue using the drug without prior authorization and at the same coverage level for the remainder of the benefit year, except in specified circumstances.
    (Note: This summary applies to this bill as introduced.)


Under Consideration


Bill Text


Sponsor Type Legislators
Prime Sponsor

Rep. E. Hooton
Sen. J. Buckner, Sen. J. Sonnenberg



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