Official Summary Text
HB2196 - 572R - House Bill Summary
ARIZONA HOUSE OF REPRESENTATIVES
57th
Legislature, 2nd Regular Session
Majority Research Staff
HB
2196
: pharmacists; pharmacies; reimbursement costs; appeals
Sponsor:
Representative Bliss, LD 1
Committee
on Health & Human Services
Overview
Prohibits
pharmacy benefit managers (PBM) from reimbursing nonaffiliated pharmacists or
pharmacies for prescription drugs or devices at an amount less than the actual
cost paid by the pharmacists or pharmacy. Requires pharmacy benefit managers to
pay a professional dispensing fee at a rate not less than the fee-for-service
methodology used in the state plan for medical assistance. Outlines
requirements for appeals, defines terms and contains an applicability clause.
History
A
PBM
means a person, business or other entity that,
pursuant to a contract or under an employment relationship with an insurer or
other third-party payor, either directly or through an intermediary manages the
prescription drug coverage provided by the insurer or other third-party payor,
including the processing and payment of claims for prescription drugs, the
performance of drug utilization review, the processing of drug prior
authorization requests, the adjudication of appeals or grievances related to prescription
drug coverage, contracting with network pharmacies and controlling the cost of
covered prescription drugs (
A.R.S. �
20-3321
).
A PBM must do all of the following: 1) update the price and
drug information for each list that the PBM maintains every seven business days;
2) at the beginning of the term of a contract, on renewal of a contract and at
least once annually during the term of a contract, make available to each
network pharmacy the sources used to determine maximum allowable cost pricing;
3) establish a process by which a network pharmacy may appeal its reimbursement
for a drug subject to maximum allowable cost pricing; and 4) allow a pharmacy
services administrative organization that is contracted with the PBM to file an
appeal of a drug on behalf of the organization's contracted pharmacies (
A.R.S. �
20-3331
).
Statute prohibits
a PBM from: 1) limiting a pharmacist or pharmacy from providing an insured
individual information on the amount of the insured�s cost share for the
insured�s prescription drug and the clinical efficacy of a more affordable
alternative; 2) penalizing a pharmacy or pharmacist for disclosing such
information to an insured; and 3) requiring a pharmacist or pharmacy to charge
or collect from an insured a copayment that exceeds the total submitted charged
by the network pharmacy
(A.R.S. � 44-1752
).
The Arizona Health
Care Cost Containment System (AHCCCS) reimburses providers on a Fee-For-Service
basis for services rendered to members eligible for AHCCCS or Arizona Long Term
Care System, who are not enrolled with a contractor or covered under prior
period coverage (
AHCCCS
).
Provisions
1.
Prohibits a
PBM from reimbursing a nonaffiliated pharmacist or pharmacy that is under
contract with the PBM for a prescription drug or device in an amount that is less
than the actual cost paid by the nonaffiliated pharmacist or pharmacy. (Sec. 1)
2.
Exempts a
PBM, that uses ingredient cost reimbursement methodology for a prescription
drug or device that is identical to the fee-for-service methodology used in the
state plan for medical assistance as approved by Centers for Medicare and
Medicaid Services, from the reimbursement restrictions. (Sec. 1)
3.
Prohibits a
PBM from including a professional dispensing fee in the amount that is
calculated to reimburse a pharmacy for a prescription drug or device in order
to satisfy the requirements. (Sec. 1)
4.
Requires a
PBM to pay a contracted pharmacy a professional dispensing fee at a rate no
less than the fee-for-service methodology used in the state plan for medical
assistance. (Sec. 1)
5.
Requires a
PBM to include in the contract with each pharmacist or pharmacy a procedure
that outlines how a pharmacist or pharmacy can appeal a reimbursement rate that
allegedly does not comply with the reimbursement restrictions. (Sec. 1)
6.
Requires a
pharmacist or pharmacy to file an appeal within seven business days after the
date on which the pharmacist or pharmacy was reimbursed for a prescription drug
or device. (Sec. 1)
7.
Requires a
PBM, beginning January 1, 2027, to file its appeal procedures with the
Department of Insurance and Financial Institutions (DIFI) and in a manner
prescribed by the DIFI. (Sec. 1)
8.
Requires
DIFI to approve or deny a PBM's appeal procedure. (Sec. 1)
9.
Requires the
appeal procedure to include a provision that allows an agent of a pharmacist or
pharmacy to submit an appeal on behalf of the pharmacist or pharmacy. (Sec. 1)
10.
Allows a
pharmacist or pharmacy to designate a pharmacy services administrative
organization or other agent to file and conduct the appeal. (Sec. 1)
11.
Requires a
PBM to complete the following within seven business days after the date a
nonaffiliated pharmacist or pharmacy prevails in an appeal of a reimbursement
cost:
a.
make the necessary change to the
challenged reimbursement or actual cost;
b.
provide the pharmacist or
pharmacy with the national drug code number for a prescription drug, if the
appeal was based on a prescription drug;
c.
allow the pharmacist or pharmacy
to reverse and rebill the claim;
d.
reimburse the pharmacist's or
pharmacy's actual cost for the prescription drug or device; and
e.
apply the findings of the appeal
to the reimbursement rate and actual cost for the prescription drug or device
to other similarly situated pharmacists and pharmacies that are reimbursed at
or below the appealed rate. (Sec. 1)
12.
Requires a
PBM to provide both of the following no later than seven business days after
prevailing on an appeal of a reimbursement cost and the prescription drug or
device that was the subject of the appeal and is available at a cost that is
equal to or less than the challenged reimbursement cost:
a.
the name of the national or
regional pharmaceutical wholesaler that does business in this state and has the
prescription drug or device in stock at a price that is equal to or less than
the challenged reimbursement cost; and
b.
the national drug code number
for the prescription drug or the unique identifier for the device, as
applicable. (Sec. 1)
13.
Requires a
PBM that does not comply with the prohibitions to:
a.
adjust the challenged
reimbursement cost to an amount that is equal to or greater than the
pharmacist's or pharmacy's actual cost; and
b.
allow the pharmacist or pharmacy
to reverse and rebill each claim that is affected by the inability to obtain
the prescription drug or device at a cost that is equal to or less than the
challenge reimbursement. (Sec. 1)
14.
Permits the
DIFI Director to establishes by rule a fee for the costs to administer the
pharmacy appeals process. (Sec. 1)
15.
Excludes
health and accident insurance coverage that is procured by the Arizona
Department of Administration from these restrictions. (Sec. 1)
16.
Defines the
following terms:
a.
nonaffiliated
pharmacist or pharmacy
;
b.
similarly
situated pharmacist or pharmacies;
and
c.
state
plan
. (Sec. 1)
17.
Applies
these provisions to contracts that are entered, amended, extended or renewed on
or after December 31, 2026. (Sec. 2)
18.
19.
20.
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Current Bill Text
Read the full stored bill text
HB2196 - 572R - I Ver
PREFILED��� JAN 09 2026
REFERENCE TITLE:
pharmacists; pharmacies; reimbursement costs; appeals
State of Arizona
House of Representatives
Fifty-seventh Legislature
Second Regular Session
2026
HB 2196
Introduced by
Representative
Bliss
AN
ACT
amending title 20, chapter 25, article 2,
arizona revised statutes, by adding section 20-3337; relating to pharmacy
benefit managers.
(TEXT OF BILL BEGINS ON NEXT PAGE)
Be it enacted by the Legislature of the State of Arizona:
Section 1. Title 20, chapter 25, article 2,
Arizona Revised Statutes, is amended by adding section 20-3337, to read:
START_STATUTE
20-3337.
Pharmacy benefit managers; prescription drugs or devices;
reimbursement costs; appeals; procedures; fee; exception; definitions
A. A pharmacy benefit manager may not
reimburse a nonaffiliated pharmacist or nonaffiliated pharmacy that is under
contract with the pharmacy benefit manager for a prescription drug or device in
an amount that is less than the actual cost paid by the nonaffiliated
pharmacist or nonaffiliated pharmacy.
B. Subsection A of this section does
not apply to a pharmacy benefit manager that uses ingredient cost reimbursement
methodology for a prescription drug or device that is identical to the fee-for-service
methodology that is used in the state plan for medical assistance as approved
by the centers for medicare and medicaid services.
C. A pharmacy benefit manager may not
include a professional dispensing fee in the amount that is calculated to
reimburse a pharmacy for a prescription drug or device to satisfy the
requirements of subsection A of this section.
D. A pharmacy benefit manager shall
pay a contracted pharmacy a professional dispensing fee at a rate not less than
The fee-for-service methodology used in the state plan for medical
assistance.
E. A pharmacy benefit manager shall
include in the contract with each pharmacist or pharmacy a procedure that
outlines how a pharmacist or pharmacy may appeal a reimbursement rate that
allegedly does not comply with subsection A of this section.� A pharmacist or
pharmacy shall file an appeal within seven business days after the date on
which the pharmacist or pharmacy was reimbursed for a prescription drug or
device.
F. Beginning January 1, 2027, a
pharmacy benefit manager shall file its appeal procedures and any amendments,
changes or revisions to the appeal procedures with the department on a form and
in a manner prescribed by the department. The department shall
approve or deny a pharmacy benefit manager's appeal procedure.� The appeal
procedure shall include a provision that allows an agent of a pharmacist or
pharmacy to submit an appeal on behalf of the pharmacist or pharmacy.� A
pharmacist or pharmacy may designate a pharmacy services administrative
organization or other agent to file and conduct the appeal.
G. If a nonaffiliated pharmacist or
nonaffiliated pharmacy prevails in an appeal of a reimbursement cost under this
section, the pharmacy benefit manager shall complete all of the following not
later than seven business days after the date the nonaffiliated pharmacist or
nonaffiliated pharmacy prevailed on appeal:
1. Make the necessary change to the
challenged reimbursement or actual cost.
2. Provide the pharmacist or pharmacy
with the national drug code number for a prescription drug, if the appeal was
based on a prescription drug.
3. Allow the pharmacist or pharmacy
to reverse and rebill the claim.
4. Reimburse the pharmacist's or
pharmacy's actual cost for the prescription drug or device.
5. Apply the findings of the appeal
to the reimbursement rate and actual cost for the prescription drug or device
to other similarly situated pharmacists and pharmacies that are reimbursed at
or below the appealed rate.�
H. If a pharmacy benefit manager
prevails in an appeal of a reimbursement cost under this section and the
prescription drug or device that is the subject of the appeal is available at a
cost that is equal to or less than the challenged reimbursement cost, the
pharmacy benefit manager shall provide to the pharmacist or pharmacy both of
the following not later than seven business days after the pharmacy benefit
manager prevailed on appeal:
1. The name of the national or
regional pharmaceutical wholesaler that does business in this state and that
has the prescription drug or device in stock at a price that is equal to or
less than the challenged reimbursement cost.
2. The national drug code number for
the prescription drug or the unique identifier for the device, as applicable.
I. If the pharmacy benefit manager
does not comply with subsection A of this section, the pharmacy benefit manager
shall:
1. Adjust the challenged
reimbursement cost to an amount that is equal to or greater than the
pharmacist's or pharmacy's actual cost.
2. Allow the pharmacist or pharmacy
to reverse and rebill each claim that is affected by the inability to obtain
the prescription drug or device at a cost that is equal to or less than the
challenged reimbursement.
J. The
director may establish by rule a fee for the costs to ADMINISTER the pharmacy
appeals process.
K. This SECTION does not apply to
health and accident insurance coverage that is procured by the department of
administration pursuant to section 38-651.
L. For the purposes of this section:
1. "nonaffiliated pharmacist or
nonaffiliated pharmacy" means a pharmacist or a pharmacy that is not
owned, directly or indirectly, by either of the following:
(
a
) A pharmacy
benefit manager company or a subsidiary of a pharmacy benefit manager.
(
b
) A company
that has an ownership interest, directly or indirectly, in a pharmacy benefit
manager.
2. "Similarly situated
pharmacists or pharmacies" means pharmacists or pharmacies that Are under
contract with a pharmacy benefit manager either directly or through a pharmacy
services contracting organization, that Purchase a prescription drug or device
that is the subject of an appeal with the pharmacy benefit manager of a
reimbursement cost that allegedly does not comply with subsection A of this
section as the pharmacist or pharmacy that prevailed in the appeal and To whom
the pharmacy benefit manager applies the challenged reimbursement rate or less
than the challenged reimbursement rate for the prescription drug or device.
3. "State plan" means the
Arizona health care cost containment system.
END_STATUTE
Sec. 2.
Applicability
Section 20-3337, Arizona Revised
Statutes, as added by this act, applies to contracts that are entered into,
amended, extended or renewed on or after December 31, 2026.