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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 act enacts the "Pharmacy Fairness Act" (act), which:

  • Requires a health insurer to submit to the commissioner of insurance (commissioner) 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;
  • 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; or
  • 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.

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 act also precludes a health insurer, a 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 act 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.

(Note: This summary applies to this bill as enacted.)


Became Law


Bill Text

The effective date for bills enacted without a safety clause is August 7, 2024, if the General Assembly adjourns sine die on May 8, 2024, unless otherwise specified. Details