RELATING TO HEALTH.

HB2225

HOUSE OF REPRESENTATIVES

H.B. NO.

2225

THIRTY-THIRD LEGISLATURE, 2026

STATE OF HAWAII

A BILL FOR AN ACT

relating
to health
.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:

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SECTION 1.
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The legislature finds that pharmacy benefit managers � third-party
companies that manage prescription drug benefits for health insurers � play a
significant role in determining access to prescription medications,
reimbursement to pharmacies, and out-of-pocket costs for beneficiaries.
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Interim staff reports issued by the Federal
Trade Commission document how pharmacy benefit managers have used spread
pricing, preferential reimbursement to affiliated pharmacies, and opaque
payment structures to extract excessive margins while reimbursing community
pharmacies below acquisition cost, contributing to pharmacy closures and
reduced access to care, particularly in rural and underserved areas.

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The legislature recognizes that when
pharmacies are reimbursed below cost or subjected to discriminatory contract
terms, patient access, medication adherence, and public health outcomes are
jeopardized.
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Ensuring fair
participation, nondiscriminatory treatment, and adequate reimbursement for
pharmacies is essential to maintaining a stable and accessible prescription
drug delivery system in Hawaii.

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The legislature further finds that
pass-through pricing models, drug pricing transparency, and the point-of-sale
application of rebates may promote accountability and better align pharmacy
benefit manager incentives with the interests of patients and payors.
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Establishing minimum reimbursement standards
tied to nationally recognized acquisition costs and professional dispensing
fees helps ensure that pharmacies are compensated fairly for services rendered,
rather than losing money on a significant majority of dispensed medications.

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The purpose of this Act is to promote
transparency and fairness in prescription drug benefit plans, prevent
discriminatory and anti-competitive practices, and ensure that cost savings are
passed on to beneficiaries rather than retained by pharmacy benefit managers
through spread pricing.

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SECTION 2.
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Chapter 431R, Hawaii Revised Statutes, is
amended by adding four new sections to be appropriately designated and to read
as follows:

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431R-A
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Nondiscrimination.
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A pharmacy benefit manager, prescription
drug benefit plan provider, prescription drug benefit plan, or third-party
payor shall not discriminate against a pharmacy or pharmacist with respect to
participation, referral, reimbursement of a covered service, or indemnification
if a pharmacist is acting with the scope of the pharmacist's license, as permitted
under state law, and the pharmacy is operating in compliance with all
applicable laws and rules.

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�431R-B
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Prescription drugs; beneficiaries; cost
sharing; deductibles.
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(a)
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A beneficiary's cost sharing for a
prescription drug shall be calculated at the point of sale based on a price
that is reduced by an amount equal to at least one hundred per cent of all
rebates that have been received, or that will be received, by the prescription
drug benefit plan provider or a pharmacy benefit manager in connection with the
administration or dispensing of the prescription drug.
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Any additional rebate in excess of the
required cost sharing shall be passed on to the prescription drug benefit plan
for the purpose of reducing premiums.

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(b)
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A prescription drug benefit plan provider shall
not increase a beneficiary's cost sharing percentage or ration at or after the
point of sale by raising the deductible, copayment, or coinsurance, or by
requiring any other out of pocket payment as a means of recouping the
dispensing cost of a pharmacist or pharmacy.

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(c)
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Any amount paid by a beneficiary for a
prescription drug shall be applied to any deductible imposed on the beneficiary
by the beneficiary's prescription drug benefit plan in accordance with the
prescription drug benefit plan's coverage documents.

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(d)
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As used in this section:

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"Cost sharing" means
any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket
cost obligation imposed by a prescription drug benefit plan on a beneficiary.

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"Rebate" means all
discounts and other negotiated price concessions paid directly or indirectly by
a pharmaceutical manufacturer or other entity, other than a beneficiary, in the
prescription drug supply chain to a pharmacy benefit manager, and that may be
based on any of the following:

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(1)
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A
pharmaceutical manufacturer's list price for a prescription drug;

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(2)
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Utilization;

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(3)
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To maintain a
net price for a prescription drug for a specified period of time for the
pharmacy benefit manager in the event the pharmaceutical manufacturer's list
price increases; or

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(4)
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Reasonable
estimates of the volume of a prescription drug that will be dispensed by a
pharmacy to beneficiaries.

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�431R-C
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Pharmacy benefit managers; reimbursement.
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(a)
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A pharmacy benefit manager shall not
reimburse any pharmacy located in the State in an amount less than the amount
that the pharmacy benefit manager reimburses a pharmacy benefit manager
affiliate for dispensing the same prescription drug as dispensed by the
pharmacy.

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(b)
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A
pharmacy benefit manager shall not reimburse any pharmacy located in the State
in an amount less than the most recently published national average drug
acquisition cost for a prescription drug on the date that the prescription drug
is administered or dispensed.
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If the
most recently published national average drug acquisition cost for the
prescription drug is unavailable on the date that the prescription drug is
administered or dispensed, a pharmacy benefit manager shall not reimburse any
pharmacy located in the State in an amount less than the wholesale acquisition
cost for the prescription drug on the date that the prescription drug is
administered or dispensed.

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(c)
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In addition to the reimbursement required
under subsection (b), a pharmacy benefit manager shall reimburse the pharmacy
or pharmacist a professional dispensing fee at the same rate as the
professional dispensing fee under the Hawaii medicaid fee schedule.

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(d)
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As used in this section:

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"National average drug
acquisition cost" means the monthly survey of retail community pharmacies
conducted by the federal Centers for Medicare and Medicaid Services to
determine average acquisition cost for medicaid covered outpatient drugs.

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"Pharmacy benefit manager
affiliate" means a pharmacy or pharmacist that directly or indirectly
through one or more intermediates, owns or controls, is owned and controlled
by, or is under common ownership or control of, a pharmacy benefit manager.

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"Wholesale acquisition
cost" has the same meaning as in title 42 United States Code section
1395w-3a(c)(6)(B).

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�431R-D
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Pharmacy benefit managers; pass-through
pricing; spread pricing.
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(a)
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All prescription drug benefit plans executed,
amended, adjusted, or renewed on or after July 1, 2027, between a pharmacy
benefit manager and a third-party payor,
or between a person and
a third-party payor, shall include all of the following requirements:

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(1)
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The pharmacy
benefit manager shall use pass-through pricing unless paragraph (2) applies;

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(2)
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The pharmacy
benefit manager may use direct or indirect spread pricing only if the
difference between the amount the third-party payor pays the pharmacy benefit
manager for a prescription drug and the amount the pharmacy benefit manager
reimburses the dispensing pharmacy or dispensing health care provider for the
prescription drug is passed through by the pharmacy benefit manager to the
person contracted to receive third-party payor services; and

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(3)
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Payments received
by a pharmacy benefit manager for services provided by the pharmacy benefit
manager to a third-party payor or a pharmacy shall be used or distributed pursuant
to the pharmacy benefit manager's contract with the third-party payor or the
pharmacy, or as otherwise required by law.

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(b)
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Unless otherwise prohibited by law, subsection
(a) shall supersede any contractual terms to the contrary in any contract
executed, amended, adjusted, or renewed on or after July 1, 2027, between a
pharmacy benefit manager and a third-party payor, or between a person and a third-party
payor.

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(c)
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As used in this section:

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"Pass-through pricing"
means a model of prescription drug pricing in which payments made by a
prescription drug benefit plan provider to a pharmacy benefit manager for
prescription drugs are equivalent to the payments the pharmacy benefit manager
makes to the dispensing pharmacy or dispensing health care provider for the
prescription drugs, including any professional dispensing fee.

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"Spread pricing" means the
method by which a pharmacy benefit manager charges a prescription drug benefit
plan provider more for prescription drugs dispensed to a beneficiary than the
amount the pharmacy benefit manager reimburses the pharmacy for dispensing
prescription drugs to a beneficiary.
"

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SECTION 3.
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Section 431R-1, Hawaii Revised Statutes, is
amended by adding a new definition to be appropriately inserted and to read as
follows:

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"
"Third-party
payor" means any entity other than a beneficiary or a health care provider
that is responsible for any amount of reimbursement for a prescription drug
benefit.
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"Third-party payor"
includes prescription drug benefit plan providers and other entities that
provide prescription drug coverage.

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"Third-party payor"
does not include:

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(1)
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The department
of human services;

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(2)
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Managed care
organizations under contract with the department of human services to provide
health care coverage for Hawaii medicaid beneficiaries; or

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(3)
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A policy or
contract providing a prescription drug benefit under medicare part D (42 U.S.C.
chapter 7, subchapter XVIII, part D).
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SECTION
4
.
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Section 431R-5, Hawaii Revised Statutes, is
amended by amending subsection (a) to read as follows:

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"(a)
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The insurance commissioner may assess a fine of
up to $10,000 for each violation by a pharmacy benefit manager or prescription drug
benefit plan provider who is in violation of section 431R-2 [
or
]
,

431R-3[
.
]
, 431R-A, 431R-B, 431R-C, or 431R-D.
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In addition, the insurance commissioner may order
the pharmacy benefit manager
or prescription drug benefit plan provider
to
take specific affirmative corrective action or make restitution."

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SECTION 5.
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In codifying the new sections added by
section 2 of this Act, the revisor of statutes shall substitute appropriate
section numbers for the letters used in designating the new sections in this
Act.

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SECTION
6.
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Statutory material to be repealed is
bracketed and stricken.
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New statutory
material is underscored.

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SECTION 7.
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This Act shall take effect upon its approval.

INTRODUCED BY:

_____________________________

Report Title:

Pharmacy
Benefit Managers; Prescription Drug Benefit Plans; Providers; Beneficiaries;
Cost Sharing; Deductibles; Reimbursement; Pass-Through Pricing; Spread Pricing

Description:

Prohibits
discrimination against a pharmacy or pharmacist with respect to participation,
referral, reimbursement of a covered service, or indemnification.
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Establishes beneficiary cost sharing and
deductible requirements for prescription drugs.
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Establishes minimum rates for which pharmacy benefit managers are to
reimburse pharmacies for dispensing prescription drugs.
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For prescription drug benefit plans executed,
amended, adjusted, or renewed on or after 7/1/2027, requires a pharmacy benefit
manager to use pass-through pricing, or may alternatively use spread pricing if
any savings realized by the pharmacy benefit manager are passed on.

The summary description
of legislation appearing on this page is for informational purposes only and is
not legislation or evidence of legislative intent.