Pharmacy benefit managers; revise provisions related to.

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To: Public Health and
Welfare
MISSISSIPPI LEGISLATURE REGULAR SESSION 2026

By: Senator(s) England

SENATE BILL NO. 2576

AN ACT TO AMEND SECTION 73-21-151, MISSISSIPPI CODE OF 1972, 1
TO REFERENCE NEW SECTIONS IN THE PHARMACY BENEFIT PROMPT PAY ACT; 2
TO AMEND SECTION 73-21-153, MISSISSIPPI CODE OF 1972, TO DEFINE 3
NEW TERMS AND REVISE THE DEFINITIONS OF EXISTING TERMS UNDER THE 4
PHARMACY BENEFIT PROMPT PAY ACT; TO AMEND SECTION 73-21-155, 5
MISSISSIPPI CODE OF 1972, TO DEFINE A CLEAN CLAIM AND A NETWORK 6
PHARMACY, FOR THE PURPOSE OF THIS SECTION; TO AMEND SECTION 7
73-21-156, MISSISSIPPI CODE OF 1972, TO REQUIRE PHARMACY BENEFIT 8
MANAGERS TO PROVIDE A REASONABLE ADMINISTRATIVE APPEAL PROCEDURE 9
TO ALLOW PHARMACIES TO CHALLENGE A REIMBURSEMENT FOR A SPECIFIC 10
DRUG OR DRUGS AS BEING BELOW THE REIMBURSEMENT RATE REQUIRED BY 11
THE PRECEDING PROVISION; TO PROVIDE THAT IF THE APPEAL IS UPHELD, 12
THE PHARMACY SHALL MAKE THE ADJUSTMENT EFFECTIVE FOR THE APPEAL 13
AND SHALL PROVIDE NOTICE ON ITS WEBSITE ABOUT THE APPEAL; TO AMEND 14
SECTION 73-21-157, MISSISSIPPI CODE OF 1972, TO REQUIRE A PHARMACY 15
SERVICES ADMINISTRATIVE ORGANIZATION (PSAO) TO BE LICENSED WITH 16
THE MISSISSIPPI BOARD OF PHARMACY; TO CREATE NEW SECTION 17
73-21-158, MISSISSIPPI CODE OF 1972, TO PROHIBIT A PHARMACY 18
BENEFIT MANAGER, PSAO, CARRIER OR HEALTH PLAN FROM SPREAD PRICING; 19
TO CREATE A NEW SECTION, THAT PROHIBITS PHARMACY BENEFIT MANAGERS 20
FROM PROVIDING FINANCIAL CONSIDERATION TO PHARMACY BENEFIT MANAGER 21
AFFILIATES AT A HIGHER RATE THAN A NONAFFILIATE; TO CREATE NEW 22
SECTION 73-21-162, MISSISSIPPI CODE OF 1972, TO PROHIBIT PHARMACY 23
BENEFIT MANAGERS, PHARMACY BENEFIT MANAGER AFFILIATES AND PHARMACY 24
SERVICES ADMINISTRATIVE ORGANIZATIONS (PSAOS) FROM PENALIZING OR 25
RETALIATING AGAINST A PHARMACIST, PHARMACY OR PHARMACY EMPLOYEE 26
FOR EXERCISING ANY RIGHTS UNDER THIS ACT, INITIATING ANY JUDICIAL 27
OR REGULATORY ACTIONS, OR APPEARING BEFORE ANY GOVERNMENTAL 28
AGENCY, LEGISLATIVE MEMBER OR BODY OR ANY JUDICIAL AUTHORITY; TO 29
AMEND SECTION 73-21-163, MISSISSIPPI CODE OF 1972, TO AUTHORIZE 30
THE BOARD OF PHARMACY, FOR THE PURPOSES OF CONDUCTING 31
INVESTIGATIONS, TO CONDUCT EXAMINATIONS OF A PHARMACY BENEFIT 32
MANAGER OR PSAO AND TO ISSUE SUBPOENAS TO OBTAIN DOCUMENTS OR 33
RECORDS THAT IT DEEMS RELEVANT TO THE INVESTIGATION; TO CREATE NEW 34
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SECTION 73-21-165, MISSISSIPPI CODE OF 1972, TO REQUIRE EACH DRUG 35
MANUFACTURER TO SUBMIT A REPORT TO THE BOARD OF PHARMACY THAT 36
INCLUDES THE CURRENT WHOLESALE ACQUISITION COST; TO REQUIRE SUCH 37
ENTITIES TO PROVIDE THE BOARD OF PHARMACY WITH VARIOUS DRUG 38
PRICING INFORMATION WITHIN A CERTAIN TIME; TO REQUIRE PHARMACY 39
BENEFIT MANAGERS AND PSAOS TO FILE A REPORT WITH THE BOARD OF 40
PHARMACY; TO REQUIRE EACH HEALTH INSURER TO SUBMIT A REPORT TO THE 41
BOARD OF PHARMACY THAT INCLUDES CERTAIN DRUG PRESCRIPTION 42
INFORMATION; TO CREATE NEW SECTION 73-21-167, MISSISSIPPI CODE OF 43
1972, TO REQUIRE THE BOARD OF PHARMACY TO DEVELOP A WEBSITE TO 44
PUBLISH INFORMATION RELATED TO THE ACT; TO CREATE NEW SECTION 45
73-21-169, MISSISSIPPI CODE OF 1972, TO REQUIRE PHARMACY BENEFIT 46
MANAGERS AND PSAOS TO IDENTIFY OWNERSHIP AFFILIATION OF ANY KIND 47
TO THE BOARD OF PHARMACY; TO CREATE A NEW SECTION THAT CREATES THE 48
MISSISSIPPI INDEPENDENT PHARMACIST REIMBURSEMENT ASSISTANCE GRANT 49
PROGRAM; TO DEFINE TERMS RELEVANT TO THE PROGRAM; TO PROVIDE 50
ELIGIBILITY REQUIREMENTS AND GUIDELINES FOR GRANT AWARDS; TO 51
PROVIDE THAT THE BOARD SHALL ESTABLISH AN APPLICATION PROCESS FOR 52
THE GRANT PROGRAM, AND THAT THE BOARD SHALL HAVE THE AUTHORITY TO 53
PROMULGATE RULES AND REGULATIONS NECESSARY TO ADMINISTERING THE 54
PROGRAM; AND FOR RELATED PURPOSES. 55
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI: 56
SECTION 1. Section 73-21-151, Mississippi Code of 1972, is 57
amended as follows: 58
73-21-151. Sections 73-21-151 through * * * 73-21-169 shall 59
be known as the "Pharmacy Benefit Prompt Pay Act." 60
SECTION 2. Section 73-21-153, Mississippi Code of 1972, is 61
amended as follows: 62
73-21-153. For purposes of Sections 73-21-151 through * * * 63
73-21-169, the following words and phrases shall have the meanings 64
ascribed herein unless the context clearly indicates otherwise: 65
(a) "Board" means the * * * Mississippi Board of 66
Pharmacy. 67
(b) "Clean claim" means a completed billing instrument, 68
paper or electronic, received by a pharmacy benefit manager from a 69
pharmacist or pharmacies or the insured, which is accepted and 70
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payment remittance advice is provided by the pharmacy benefit 71
manager. A clean claim includes resubmitted claims with 72
previously identified deficiencies corrected. 73
( * * *c) "Commissioner" means the Mississippi 74
Commissioner of Insurance. 75
( * * *d) "Day" means a calendar day, unless otherwise 76
defined or limited. 77
( * * *e) "Electronic claim" means the transmission of 78
data for purposes of payment of covered prescription drugs, other 79
products and supplies, and pharmacist services in an electronic 80
data format specified by a pharmacy benefit manager and approved 81
by the department. 82
( * * *f) "Electronic adjudication" means the process 83
of electronically receiving * * * and reviewing an electronic 84
claim and either accepting and providing payment remittance advice 85
for the electronic claim or rejecting * * * the electronic claim. 86
( * * *g) "Enrollee" means an individual who has been 87
enrolled in a pharmacy benefit management plan or health insurance 88
plan. 89
( * * *h) "Health insurance plan" means benefits 90
consisting of prescription drugs, other products and supplies, and 91
pharmacist services provided directly, through insurance or 92
reimbursement, or otherwise and including items and services paid 93
for as prescription drugs, other products and supplies, and 94
pharmacist services under any hospital or medical service policy 95
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or certificate, hospital or medical service plan contract, 96
preferred provider organization agreement, or health maintenance 97
organization contract offered by a health insurance issuer. 98
(i) "Network pharmacy" means a pharmacy licensed by the 99
board and provides pharmacy services to Mississippi consumers and 100
has a contract with a pharmacy benefit manager to provide covered 101
drugs at a negotiated reimbursement rate. 102
(j) "Payment remittance advice" means the claim detail 103
that the pharmacy receives when successfully processing an 104
electronic or paper claim. The claim detail shall contain, but is 105
not limited to: 106
(i) The amount that the pharmacy benefit manager 107
will reimburse for product ingredient; 108
(ii) The amount that the pharmacy benefit manager 109
will reimburse for product dispensing fee; and 110
(iii) The amount that the pharmacy benefit manager 111
dictates the patient must pay. 112
(k) "Pharmacist * * *" and "pharmacy" * * * shall have 113
the same definitions as provided in Section 73-21-73. 114
( * * *l) "Pharmacy benefit manager" * * * means an 115
entity that provides pharmacy benefit management services. * * * 116
The term "pharmacy benefit manager" shall not include: 117
(i) An insurance company unless the insurance 118
company is providing services as a pharmacy benefit manager * * *, 119
in which case the insurance company shall be subject to Sections 120
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73-21-151 through * * * 73-21-169 only for those pharmacy benefit 121
manager services * * *; and 122
(ii) The Mississippi Division of Medicaid or its 123
contractors when performing pharmacy benefit manager services for 124
the Division of Medicaid. 125
( * * *m) "Pharmacy benefit manager affiliate" 126
means * * * an entity that directly or indirectly * * * owns or 127
controls, is owned or controlled by, or is under common ownership 128
or control with a pharmacy benefit manager. 129
( * * *n) "Pharmacy benefit management plan" * * * 130
means an arrangement for the delivery of pharmacist's services in 131
which a pharmacy benefit manager undertakes to administer the 132
payment or reimbursement of any of the costs of pharmacist's 133
services, drugs or devices. 134
* * * 135
(o) "Pharmacy benefit management services" shall 136
include, but is not limited to, the following services, which may 137
be provided either directly or through outsourcing or contracts: 138
(i) Adjudicate drug claims or any portion of the 139
transaction. 140
(ii) Contract with retail and mail pharmacy 141
networks. 142
(iii) Establish payment levels for pharmacies. 143
(iv) Develop formulary or drug lists of covered 144
therapies. 145
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(v) Provide benefit design consultation. 146
(vi) Manage cost and utilization trends. 147
(vii) Contract for manufacturer rebates. 148
(viii) Provide fee-based clinical services to 149
improve member care. 150
(ix) Third-party administration. 151
(p) "Pharmacist services" means products, goods and 152
services, or any combination of products, goods and services, 153
provided as part of the practice of pharmacy. 154
(q) "Pharmacy services administrative organization" or 155
"PSAO" means any entity that contracts with a pharmacy or 156
pharmacist to assist with third-party interactions and that may 157
provide a variety of other administrative services, including, but 158
not limited to, contracting with pharmacy benefit managers on 159
behalf of pharmacies and providing pharmacies with credentialing, 160
billing, auditing, general business and analytic support. A 161
covered entity as defined in 42 USC Section 256b, including its 162
pharmacy or the transactions related to the 340B drug discount 163
program of any pharmacy contracted with the participating covered 164
entity to dispense drugs purchased through the 340B drug discount 165
program, shall not be considered to be a pharmacy services 166
administrative organization. 167
( * * *r) "Plan sponsors" means the employers, 168
insurance companies, unions and health maintenance organizations 169
that contract, either directly or indirectly, with a pharmacy 170
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benefit manager for delivery of prescription drugs and/or 171
services. 172
(s) "Proprietary information" means information on 173
pricing, costs, revenue, taxes, market share, negotiating 174
strategies, customers and personnel that is held by a pharmacy 175
benefit manager or PSAO and used for its business purposes. 176
(t) "Rebate" means any and all payments and price 177
concessions that accrue to a pharmacy benefit manager or its plan 178
sponsor client, directly or indirectly, including through an 179
affiliate, subsidiary, third party or intermediary, including 180
off-shore group purchasing organizations, from a pharmaceutical 181
manufacturer, its affiliate, subsidiary, third party or 182
intermediary, including, but not limited to, payments, discounts, 183
administration fees, credits, incentives or penalties associated 184
directly or indirectly in any way with claims administered on 185
behalf of a plan sponsor. 186
(u) "Spread pricing" means any amount charged or 187
claimed by a pharmacy benefit manager or PSAO in excess of the 188
ingredient cost for a dispensed prescription drug plus dispensing 189
fee paid directly or indirectly to any pharmacy, pharmacist or 190
other provider on behalf of the health benefit plan, less a 191
pharmacy benefit management or PSAO fee. 192
( * * *v) "Uniform claim form" means a form prescribed 193
by rule by the * * * board; however, for purposes of Sections 194
73-21-151 through * * * 73-21-169, the board shall adopt the same 195
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definition or rule where the State Department of Insurance has 196
adopted a rule covering the same type of claim. The board may 197
modify the terminology of the rule and form when necessary to 198
comply with the provisions of Sections 73-21-151 through * * * 199
73-21-169. 200
(w) "Wholesale acquisition cost" means the wholesale 201
acquisition cost of the drug as defined in 42 USC§ 202
1395w-3a(c)(6)(B). 203
SECTION 3. Section 73-21-155, Mississippi Code of 1972, is 204
amended as follows: 205
73-21-155. (1) Reimbursement under a contract to a 206
pharmacist or pharmacy for prescription drugs and other products 207
and supplies that is calculated according to a formula that uses 208
Medi-Pan, Gold Standard or a nationally recognized reference that 209
has been approved by the board in the pricing calculation shall 210
use the most current reference price or amount in the actual or 211
constructive possession of the pharmacy benefit manager, its 212
agent, or any other party responsible for reimbursement for 213
prescription drugs and other products and supplies on the date of 214
electronic adjudication or on the date of service shown on the 215
nonelectronic claim. 216
(2) Pharmacy benefit managers, their agents and other 217
parties responsible for reimbursement for prescription drugs and 218
other products and supplies shall be required to update the 219
nationally recognized reference prices or amounts used for 220
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calculation of reimbursement for prescription drugs and other 221
products and supplies no less than every three (3) business days. 222
(3) (a) All benefits payable under a pharmacy benefit 223
management plan shall be paid within seven (7) days after receipt 224
of due written proof a clean claim where claims are submitted 225
electronically, and shall be paid within thirty-five (35) days 226
after receipt of due written proof of a clean claim where claims 227
are submitted in paper format. Benefits due under the plan and 228
claims are overdue if not paid within seven (7) days or 229
thirty-five (35) days, whichever is applicable, after the pharmacy 230
benefit manager receives a clean claim containing necessary 231
information essential for the pharmacy benefit manager to 232
administer preexisting condition, coordination of benefits and 233
subrogation provisions under the plan sponsor's health insurance 234
plan. A "clean claim" means a * * * completed billing instrument, 235
paper or electronic, received by a pharmacy benefit manager from a 236
pharmacist or pharmacies or the insured, which is accepted and 237
payment remittance advice is provided by the pharmacy benefit 238
manager. A clean claim includes resubmitted claims with 239
previously identified deficiencies corrected. 240
(b) A clean claim does not include any of the 241
following: 242
(i) A duplicate claim, which means an original 243
claim and its duplicate when the duplicate is filed within thirty 244
(30) days of the original claim; 245
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(ii) Claims which are submitted fraudulently or 246
that are based upon material misrepresentations; 247
(iii) Claims that require information essential 248
for the pharmacy benefit manager to administer preexisting 249
condition, coordination of benefits or subrogation provisions 250
under the plan sponsor's health insurance plan; or 251
(iv) Claims submitted by a pharmacist or pharmacy 252
more than thirty (30) days after the date of service; if the 253
pharmacist or pharmacy does not submit the claim on behalf of the 254
insured, then a claim is not clean when submitted more than thirty 255
(30) days after the date of billing by the pharmacist or pharmacy 256
to the insured. 257
(c) Not later than seven (7) days after the date the 258
pharmacy benefit manager actually receives an electronic claim, 259
the pharmacy benefit manager shall pay the appropriate benefit in 260
full, or any portion of the claim that is clean, and notify the 261
pharmacist or pharmacy (where the claim is owed to the pharmacist 262
or pharmacy) of the reasons why the claim or portion thereof is 263
not clean and will not be paid and what substantiating 264
documentation and information is required to adjudicate the claim 265
as clean. Not later than thirty-five (35) days after the date the 266
pharmacy benefit manager actually receives a paper claim, the 267
pharmacy benefit manager shall pay the appropriate benefit in 268
full, or any portion of the claim that is clean, and notify the 269
pharmacist or pharmacy (where the claim is owed to the pharmacist 270
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or pharmacy) of the reasons why the claim or portion thereof is 271
not clean and will not be paid and what substantiating 272
documentation and information is required to adjudicate the claim 273
as clean. Any claim or portion thereof resubmitted with the 274
supporting documentation and information requested by the pharmacy 275
benefit manager shall be paid within twenty (20) days after 276
receipt. 277
(4) If the board finds that any pharmacy benefit manager, 278
agent or other party responsible for reimbursement for 279
prescription drugs and other products and supplies has not paid 280
ninety-five percent (95%) of clean claims as defined in subsection 281
(3) of this section received from all pharmacies in a calendar 282
quarter, he shall be subject to administrative penalty of not more 283
than Twenty-five Thousand Dollars ($25,000.00) to be assessed by 284
the State Board of Pharmacy. 285
(a) Examinations to determine compliance with this 286
subsection may be conducted by the board. The board may contract 287
with qualified impartial outside sources to assist in examinations 288
to determine compliance. The expenses of any such examinations 289
shall be paid by the pharmacy benefit manager examined. 290
(b) Nothing in the provisions of this section shall 291
require a pharmacy benefit manager to pay claims that are not 292
covered under the terms of a contract or policy of accident and 293
sickness insurance or prepaid coverage. 294
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(c) If the claim is not denied for valid and proper 295
reasons by the end of the applicable time period prescribed in 296
this provision, the pharmacy benefit manager must pay the pharmacy 297
(where the claim is owed to the pharmacy) or the patient (where 298
the claim is owed to a patient) interest on accrued benefits at 299
the rate of one and one-half percent (1-1/2%) per month accruing 300
from the day after payment was due on the amount of the benefits 301
that remain unpaid until the claim is finally settled or 302
adjudicated. Whenever interest due pursuant to this provision is 303
less than One Dollar ($1.00), such amount shall be credited to the 304
account of the person or entity to whom such amount is owed. 305
(d) Any pharmacy benefit manager and a pharmacy may 306
enter into an express written agreement containing timely claim 307
payment provisions which differ from, but are at least as 308
stringent as, the provisions set forth under subsection (3) of 309
this section, and in such case, the provisions of the written 310
agreement shall govern the timely payment of claims by the 311
pharmacy benefit manager to the pharmacy. If the express written 312
agreement is silent as to any interest penalty where claims are 313
not paid in accordance with the agreement, the interest penalty 314
provision of subsection (4)(c) of this section shall apply. 315
(e) The State Board of Pharmacy may adopt rules and 316
regulations necessary to ensure compliance with this subsection. 317
(5) (a) For purposes of this subsection (5), "network 318
pharmacy" means a licensed pharmacy in this state that has a 319
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contract with a pharmacy benefit manager to provide covered drugs 320
at a negotiated reimbursement rate. A network pharmacy or 321
pharmacist may decline to provide a brand name drug, multisource 322
generic drug, or service, if the network pharmacy or pharmacist is 323
paid less than that network pharmacy's acquisition cost for the 324
product. If the network pharmacy or pharmacist declines to 325
provide such drug or service, the pharmacy or pharmacist shall 326
provide the customer with adequate information as to where the 327
prescription for the drug or service may be filled. 328
(b) The State Board of Pharmacy shall adopt rules and 329
regulations necessary to implement and ensure compliance with this 330
subsection, including, but not limited to, rules and regulations 331
that address access to pharmacy services in rural or underserved 332
areas in cases where a network pharmacy or pharmacist declines to 333
provide a drug or service under paragraph (a) of this subsection. 334
The board shall promulgate the rules and regulations required by 335
this paragraph (b) not later than October 1, 2016. 336
(6) A pharmacy benefit manager shall not directly or 337
indirectly retroactively deny or reduce a claim or aggregate of 338
claims after the claim or aggregate of claims has been 339
adjudicated. 340
SECTION 4. Section 73-21-156, Mississippi Code of 1972, is 341
amended as follows: 342
73-21-156. (1) As used in this section, the following terms 343
shall be defined as provided in this subsection: 344
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(a) "Maximum allowable cost list" means a listing of 345
drugs or other methodology used by a pharmacy benefit manager, 346
directly or indirectly, setting the maximum allowable payment to a 347
pharmacy or pharmacist for a generic drug, brand-name drug, 348
biologic product or other prescription drug. The term "maximum 349
allowable cost list" includes without limitation: 350
(i) Average acquisition cost, including national 351
average drug acquisition cost; 352
(ii) Average manufacturer price; 353
(iii) Average wholesale price; 354
(iv) Brand effective rate or generic effective 355
rate; 356
(v) Discount indexing; 357
(vi) Federal upper limits; 358
(vii) Wholesale acquisition cost; and 359
(viii) Any other term that a pharmacy benefit 360
manager or a health care insurer may use to establish 361
reimbursement rates to a pharmacist or pharmacy for pharmacist 362
services. 363
(b) "Pharmacy acquisition cost" means the amount that a 364
pharmaceutical wholesaler charges for a pharmaceutical product as 365
listed on the pharmacy's billing invoice. 366
(2) Before a pharmacy benefit manager places or continues a 367
particular drug on a maximum allowable cost list, the drug: 368
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(a) If the drug is a generic equivalent drug product as 369
defined in Section 73-21-73, shall be listed as therapeutically 370
equivalent and pharmaceutically equivalent "A" or "B" rated in the 371
United States Food and Drug Administration's most recent version 372
of the "Orange Book" or "Green Book" or have an NR or NA rating by 373
Medi-Span, Gold Standard, or a similar rating by a nationally 374
recognized reference approved by the board; 375
(b) Shall be available for purchase by each pharmacy in 376
the state from national or regional wholesalers operating in 377
Mississippi; and 378
(c) Shall not be obsolete. 379
(3) A pharmacy benefit manager shall: 380
(a) Provide access to its maximum allowable cost list 381
to each pharmacy subject to the maximum allowable cost list; 382
(b) Update its maximum allowable cost list on a timely 383
basis, but in no event longer than three (3) calendar days; and 384
(c) Provide a process for each pharmacy subject to the 385
maximum allowable cost list to receive prompt notification of an 386
update to the maximum allowable cost list. 387
(4) A pharmacy benefit manager shall: 388
(a) Provide a reasonable administrative appeal 389
procedure to allow pharmacies to challenge * * * reimbursements 390
made * * * for a specific drug or drugs as: 391
(i) Not meeting the requirements of this section; 392
or 393
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(ii) Being below the pharmacy acquisition cost. 394
(b) The reasonable administrative appeal procedure 395
shall include the following: 396
(i) A * * * direct telephone number, email address 397
and website for the purpose of submitting administrative appeals; 398
(ii) The website of the pharmacy benefit manager 399
shall include easily accessible administrative appeal 400
instructions, including listing any required information to be 401
submitted by pharmacies for the purpose of submitting 402
administrative appeals 403
( * * *iii) The ability to submit an 404
administrative appeal or a claim appeal report for multiple claims 405
directly to the pharmacy benefit manager * * * or through a 406
pharmacy service administrative organization; and 407
( * * *iv) A period of no less than thirty (30) 408
business days to file an administrative appeal. 409
(c) The pharmacy benefit manager shall respond to the 410
challenge under paragraph (a) of this subsection (4) within thirty 411
(30) * * * days after receipt of the challenge. 412
(d) If a challenge is made under paragraph (a) of this 413
subsection (4), the pharmacy benefit manager shall within thirty 414
(30) * * * days after receipt of the challenge either: 415
(i) * * * Uphold the appeal * * * and adjust the 416
reimbursement paid to the pharmacist or pharmacy to no less than 417
the pharmacy acquisition cost, as documented on the pharmacist's 418
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and pharmacy's billing invoice, or as provided in the claim appeal 419
report, and make the adjustment effective for that pharmacist or 420
pharmacy for the appeal. The pharmacy benefit manager shall 421
provide notice on its website that an appeal was made and upheld 422
and that an adjusted reimbursement was made to a pharmacy or 423
pharmacist following the appeal. The notice shall include the 424
National Drug Code, the day of service for which the appeal was 425
made and the challenged rate; 426
(ii) * * * Deny the appeal and provide the 427
challenging pharmacy or pharmacist the National Drug Code and the 428
name of the national or regional pharmaceutical wholesalers 429
operating in Mississippi that the pharmacy or pharmacist is able 430
to purchase prescription drugs for resale from and that have the 431
drug currently in stock at a price below the maximum allowable 432
cost as listed on the maximum allowable cost list; or 433
(iii) If the National Drug Code provided by the 434
pharmacy benefit manager is not available below the pharmacy 435
acquisition cost from the pharmaceutical wholesaler from whom the 436
pharmacy or pharmacist purchases the majority of prescription 437
drugs for resale, then the pharmacy benefit manager shall adjust 438
the maximum allowable cost as listed on the maximum allowable cost 439
list above the challenging pharmacy's pharmacy acquisition cost 440
and permit the pharmacy to reverse and rebill each claim affected 441
by the inability to procure the drug at a cost that is equal to or 442
less than the previously challenged maximum allowable cost. 443
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(e) The board may adopt rules and regulations necessary 444
to ensure compliance with this subsection. 445
(5) A pharmacy or pharmacist that belongs to a PSAO shall be 446
provided a true and correct copy of any contract and contract 447
amendment that the PSAO enters into with a pharmacy benefit 448
manager or third-party payer on the pharmacy or pharmacist's 449
behalf. 450
(6) A pharmacy benefit manager shall not deny an appeal 451
submitted pursuant to subsection (4) of this section based upon an 452
existing contract with the pharmacy that provides for a 453
reimbursement rate lower than the pharmacy acquisition cost. 454
SECTION 5. Section 73-21-157, Mississippi Code of 1972, is 455
amended as follows: 456
73-21-157. (1) Before beginning to do business as a 457
pharmacy benefit manager or PSAO, a pharmacy benefit manager or 458
PSAO shall obtain a license to do business from the board. To 459
obtain a license, the applicant shall submit an application to the 460
board on a form to be prescribed by the board. This license shall 461
be renewed annually. 462
(2) When applying for a license or renewal of a license, 463
each pharmacy benefit manager * * * or PSAO shall file * * * with 464
the board * * *: 465
(a) A copy of a certified audit report, if the pharmacy 466
benefit manager has been audited by a certified public accountant 467
within the last twenty-four (24) months; or 468
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( * * *b) If the pharmacy benefit manager has not been 469
audited in the last twenty-four (24) months, a financial statement 470
of the organization, including its balance sheet and income 471
statement for the preceding year which shall be verified by at 472
least two (2) principal officers; and 473
( * * *c) Any other information relating to the 474
operations of the pharmacy benefit manager required by the 475
board * * *. 476
( * * *3) (a) Any information required to be submitted to 477
the board pursuant to licensure application that is considered 478
proprietary by a pharmacy benefit manager or PSAO shall be marked 479
as confidential when submitted to the board. All such information 480
shall not be subject to the provisions of the federal Freedom of 481
Information Act or the Mississippi Public Records Act and shall 482
not be released by the board unless subject to an order from a 483
court of competent jurisdiction. The board shall destroy or 484
delete or cause to be destroyed or deleted all such information 485
thirty (30) days after the board determines that the information 486
is no longer necessary or useful. 487
(b) Any person who knowingly releases, causes to be 488
released or assists in the release of any such information shall 489
be subject to a monetary penalty imposed by the board in an amount 490
not exceeding Fifty Thousand Dollars ($50,000.00) per violation. 491
When the board is considering the imposition of any penalty under 492
this paragraph (b), it shall follow the same policies and 493
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procedures provided for the imposition of other sanctions in the 494
Pharmacy Practice Act. Any penalty collected under this paragraph 495
(b) shall be deposited into the special fund of the board and used 496
to support the operations of the board relating to the regulation 497
of pharmacy benefit managers. 498
(c) All employees of the board who have access to the 499
information described in paragraph (a) of this subsection shall be 500
fingerprinted, and the board shall submit a set of fingerprints 501
for each employee to the Department of Public Safety for the 502
purpose of conducting a criminal history records check. If no 503
disqualifying record is identified at the state level, the 504
Department of Public Safety shall forward the fingerprints to the 505
Federal Bureau of Investigation for a national criminal history 506
records check. 507
( * * *4) * * * The board may waive the requirements for 508
filing financial information for the pharmacy benefit manager if 509
an affiliate of the pharmacy benefit manager is already required 510
to file such information under current law with the Commissioner 511
of Insurance and allow the pharmacy benefit manager to file a copy 512
of documents containing such information with the board in lieu of 513
the statement required by this section. 514
( * * *5) The expense of administering this section shall be 515
assessed annually by the board against all pharmacy benefit 516
managers and PSAOs operating in this state. 517
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( * * *6) A pharmacy benefit manager, PSAO or third-party 518
payor * * * shall not require pharmacy accreditation standards 519
or * * * certification requirements inconsistent with, more 520
stringent than, or in addition to federal and state requirements 521
for licensure as a pharmacy in this state. 522
SECTION 6. The following shall be codified as Section 523
73-21-158, Mississippi Code of 1972: 524
73-21-158. (1) No pharmacy benefit manager, PSAO, carrier 525
or health benefit plan may, either directly or through an 526
intermediary, agent or affiliate engage in, facilitate or enter 527
into a contract with another person involving spread pricing in 528
this state. 529
(2) A pharmacy benefit manager or PSAO contract with a 530
carrier or health benefit plan entered into, renewed or amended on 531
or after the effective date of this act must: 532
(a) Specify all forms of revenue, including pharmacy 533
benefit management or PSAO fees, to be paid by the carrier or 534
health benefit plan to the pharmacy benefit manager or PSAO; and 535
(b) Acknowledge that spread pricing is not permitted in 536
accordance with this section. 537
(3) Subsections (1) and (2) of this section shall not apply 538
to self-insured plans. 539
(4) Every pharmacy benefit manager and PSAO shall disclose 540
to the plan sponsor or employer one hundred percent (100%) of all 541
rebates and other payments that the pharmacy benefit manager or 542
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PSAO receives directly or indirectly from pharmaceutical 543
manufacturers and/or rebate aggregators in connection with claims 544
administered on behalf of the plan sponsor or employer and the 545
recipients of such rebates. In addition, a pharmacy benefit 546
manager or PSAO shall report annually to each plan sponsor or 547
employer the aggregate amount of all rebates and 548
other payments and the recipients of such rebates unless the 549
contract with the plan sponsor or employer or the health benefit 550
plan already requires these disclosures. 551
(5) A pharmacy benefit manager or third-party payer shall 552
not charge or cause a patient to pay an amount that exceeds the 553
total amount retained by the pharmacy. 554
SECTION 7. A pharmacy benefit manager shall not reimburse, 555
compensate or otherwise provide financial consideration to a 556
pharmacy benefit manager affiliated at a higher rate than a non 557
affiliated pharmacy for the same drug and the same pharmacy 558
service solely on the basis of common ownership, control or 559
corporate affiliation. 560
The reimbursement amount for purposes of this section shall 561
be evaluated on a per-unit basis using the same brand or generic 562
product identifier or National Drug Code and the same pharmacy 563
service. 564
Designation of a pharmacy as a specialty pharmacy, or 565
differential reimbursement associated with specialty pharmacy 566
services, shall be based on objective, clinically appropriate and 567
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operational criteria related to patient care, safety, service 568
capabilities or regulatory requirements, and shall not be based 569
solely on ownership or corporate affiliation. 570
A pharmacy that meets the disclosed participation criteria 571
applicable to a pharmacy network, including any specialty pharmacy 572
requirements, shall be eligible to participate in that network on 573
the same terms and conditions as a similarly situated affiliated 574
pharmacy. 575
Nothing in this section shall be construed to prohibit a 576
pharmacy benefit manager or health benefit plan from encouraging, 577
incentivizing or steering utilization to a pharmacy based on 578
cost-effectiveness, delivery method, service model, performance 579
metrics or volume-based arrangements, provided such criteria are 580
applied uniformly to affiliated and non-affiliated pharmacies. 581
Nothing in this section shall be construed to prohibit bona 582
fide volume-based discounts, rebates or other price concessions 583
offered on equal terms to all similarly situated in-network 584
pharmacies, including affiliated and non-affiliated pharmacies. 585
SECTION 8. The following shall be codified as Section 586
73-21-162, Mississippi Code of 1972: 587
73-21-162. (1) Retaliation is prohibited. 588
(a) A pharmacy benefit manager, pharmacy benefit 589
manager affiliate or a PSAO shall not retaliate against a 590
pharmacist or pharmacy based on the pharmacist's or pharmacy's 591
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exercise of any right or remedy under this chapter. Retaliation 592
prohibited by this section includes, but is not limited to: 593
(i) termination or refusing to renew a contract 594
with the pharmacist or pharmacy; 595
(ii) Subjecting the pharmacist or pharmacy to an 596
increase frequency of audits, numbers of claims audited or amount 597
of monies for claims audited; or 598
(iii) Failing to promptly pay the pharmacist or 599
pharmacy any money owed by the pharmacy benefit manager to the 600
pharmacist or pharmacy. 601
(b) For the purposes of this section, a pharmacy 602
benefit manager, pharmacy benefit manager affiliate or PSAO is not 603
considered to have retaliated against a pharmacy if the pharmacy 604
benefit manager: 605
(i) Takes an action in response to a credible 606
allegation of fraud against the pharmacist or pharmacy; and 607
(ii) Provides reasonable notice to the pharmacist 608
or pharmacy of the allegation of fraud and the basis of the 609
allegation before initiating an action. 610
(2) A pharmacy benefit manager, pharmacy benefit manager 611
affiliate or PSAO shall not penalize or retaliate against a 612
pharmacist, pharmacy or pharmacy employee for exercising any 613
rights under this chapter, initiating any judicial or regulatory 614
actions or discussing or disclosing information pertaining to an 615
agreement with a pharmacy benefit manager or a pharmacy benefit 616
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manager affiliate when testifying or otherwise appearing before 617
any governmental agency, legislative member or body or any 618
judicial authority. 619
SECTION 9. Section 73-21-163, Mississippi Code of 1972, is 620
amended as follows: 621
73-21-163. (1) Whenever the board has reason to believe 622
that a pharmacy benefit manager * * *, pharmacy benefit manager 623
affiliate or PSAO is using, has used, or is about to use any 624
method, act or practice prohibited in * * * this act and that 625
proceedings would be in the public interest, it may bring an 626
action in the name of the board against the pharmacy benefit 627
manager * * *, pharmacy benefit manager affiliate or PSAO to 628
restrain by temporary or permanent injunction the use of such 629
method, act or practice. The action shall be brought in the 630
Chancery Court of the First Judicial District of Hinds County, 631
Mississippi. The court is authorized to issue temporary or 632
permanent injunctions to restrain and prevent violations of * * * 633
this act and such injunctions shall be issued without bond. 634
(2) The board may impose a monetary penalty on a pharmacy 635
benefit manager * * *, a pharmacy benefit manager affiliate or 636
PSAO for noncompliance with the provisions of * * * this act, in 637
amounts of not less than One Thousand Dollars ($1,000.00) per 638
violation and not more than Twenty-five Thousand Dollars 639
($25,000.00) per violation. Each day a violation continues for 640
the same brand or generic product identifier or brand or generic 641
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code number is a separate violation. Each day that a pharmacy 642
benefit manager or PSAO does business in this state without a 643
license is deemed a separate violation. The board shall prepare a 644
record entered upon its minutes that states the basic facts upon 645
which the monetary penalty was imposed. Any penalty collected 646
under this subsection (2) shall be deposited into the special fund 647
of the board. 648
(3) For the purposed of conduction investigations, the 649
board, through its executive director, may conduct audits and 650
examinations of a pharmacy benefit manger or PSAO and may also 651
issue subpoenas to any pharmacy, pharmacy benefit manager, PSAO or 652
have documents or records that it deems relevant to the 653
investigation. 654
( * * *4) The board may assess a monetary penalty for those 655
reasonable costs that are expended by the board in the 656
investigation and conduct of a proceeding if the board imposes a 657
monetary penalty under subsection (2) of this section. A monetary 658
penalty assessed and levied under this section shall be paid to 659
the board by the licensee, registrant or permit holder upon the 660
expiration of the period allowed for appeal of those penalties 661
under Section 73-21-101, or may be paid sooner if the licensee, 662
registrant or permit holder elects. Any penalty collected by the 663
board under this subsection ( * * *4) shall be deposited into the 664
special fund of the board. 665
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( * * *5) When payment of a monetary penalty assessed and 666
levied by the board against a licensee, registrant or permit 667
holder in accordance with this section is not paid by the 668
licensee, registrant or permit holder when due under this section, 669
the board shall have the power to institute and maintain 670
proceedings in its name for enforcement of payment in the chancery 671
court of the county and judicial district of residence of the 672
licensee, registrant or permit holder, or if the licensee, 673
registrant or permit holder is a nonresident of the State of 674
Mississippi, in the Chancery Court of the First Judicial District 675
of Hinds County, Mississippi. When those proceedings are 676
instituted, the board shall certify the record of its proceedings, 677
together with all documents and evidence, to the chancery court 678
and the matter shall be heard in due course by the court, which 679
shall review the record and make its determination thereon in 680
accordance with the provisions of Section 73-21-101. The hearing 681
on the matter may, in the discretion of the chancellor, be tried 682
in vacation. 683
(6) (a) The board may conduct audits to ensure compliance 684
with the provisions of this act. In conducting audits, the board 685
is empowered to request production of documents pertaining to 686
compliance with the provisions of this act, and documents so 687
requested shall be produced within thirty (30) days of the request 688
unless extended by the board or its duly authorized staff. 689
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(b) If, after the conclusion of the audit, the pharmacy 690
benefit manager or PSAO was found to be in compliance with all of 691
the requirements of this act, then the board shall pay the costs 692
of the audit. However, the pharmacy benefit manager or PSAO being 693
audited shall pay all costs of such audit if such audit reveals 694
any noncompliance with this act. The cost of the audit 695
examination shall be deposited into the special fund and shall be 696
used by the board, upon appropriation of the Legislature, to 697
support the operations of the board relating to the regulation of 698
pharmacy benefit managers. 699
(c) The board is authorized to hire independent 700
consultants to conduct audits of a pharmacy benefit manager and 701
expend funds collected under this section to pay the cost of 702
performing audit services. 703
( * * *7) The board shall develop and implement a uniform 704
penalty policy that sets the minimum and maximum penalty for any 705
given violation of * * * this act. The board shall adhere to its 706
uniform penalty policy except in those cases where the board 707
specifically finds, by majority vote, that a penalty in excess of, 708
or less than, the uniform penalty is appropriate. That vote shall 709
be reflected in the minutes of the board and shall not be imposed 710
unless it appears as having been adopted by the board. 711
SECTION 10. The following shall be codified as Section 712
73-21-165, Mississippi Code of 1972: 713
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73-21-165. (1) Each drug manufacturer shall submit a report 714
to the board no later than the fifteenth day of January, April, 715
July and October with the current wholesale acquisition cost 716
information for the prescription drugs sold in or into the state 717
by that drug manufacturer; provided, however, the first report due 718
under this subsection shall not be due until October 1, 2026. 719
(2) Not more than thirty (30) days after an increase in 720
wholesale acquisition cost of forty percent (40%) or greater over 721
the preceding five (5) calendar years or ten percent (10%) or 722
greater in the preceding twelve (12) months for a prescription 723
drug with a wholesale acquisition cost of Seventy Dollars ($70.00) 724
or more for a manufacturer-packaged drug container, a drug 725
manufacturer shall submit a report to the board. The report must 726
contain the following information: 727
(a) The name of the drug; 728
(b) Whether the drug is a brand name or a generic; 729
(c) The effective date of the change in wholesale 730
acquisition cost; 731
(d) Aggregate, company-level research and development 732
costs for the previous calendar year; 733
(e) Aggregate rebate amounts paid to each pharmacy 734
benefit manager or PSAO for the previous calendar year; 735
(f) The name of each of the drug manufacturer's drugs 736
approved by the United States Food and Drug Administration in the 737
previous five (5) calendar years; 738
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(g) The name of each of the drug manufacturer's drugs 739
that lost patent exclusivity in the United States in the previous 740
five (5) calendar years; and 741
(h) A concise statement of rationale regarding the 742
factor or factors that caused the increase in the wholesale 743
acquisition cost, such as raw ingredient shortage or increase in 744
pharmacy benefit manager's or PSAO's rebates. 745
(3) A manufacturer's obligations under this section shall be 746
fully satisfied by the submission of any information and data that 747
a manufacturer includes in the manufacturer's annual consolidated 748
report on Securities and Exchange Form 10-K or any other public 749
disclosure. A drug manufacturer shall notify the board in writing 750
if the drug manufacturer is introducing a new prescription drug to 751
market at a wholesale acquisition cost that exceeds the threshold 752
set for a specialty drug under the Medicare Part D Program. 753
(4) The notice must include a concise statement of rationale 754
regarding the factor or factors that caused the new drug to exceed 755
the Medicare Part D Program price. The drug manufacturer shall 756
provide the written notice within three (3) calendar days 757
following the release of the drug in the commercial market. A 758
drug manufacturer may make the notification pending approval by 759
the United States Food and Drug Administration if commercial 760
availability is expected within three (3) calendar days following 761
the approval. 762
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(5) On or before October 1st of each year, a pharmacy 763
benefit manager or PSAO providing services for a health care plan 764
shall file a report with the board. The report must contain the 765
following information for the previous state fiscal year: 766
(a) The aggregated rebates, fees, price protection 767
payments, and any other payments collected from each drug 768
manufacturer; 769
(b) The aggregated dollar amount of rebates, price 770
protection payments, fees and any other payments collected from 771
each drug manufacturer which were passed to health insurers; 772
(c) The aggregated fees, price concessions, penalties, 773
effective rates, and any other financial incentive collected from 774
pharmacies which were passed to enrollees at the point of sale; 775
(d) The aggregated dollar amount of rebates, price 776
protection payments, fees, and any other payments collected from 777
drug manufacturers which were retained as revenue by the pharmacy 778
benefit manager or PSAO; and 779
(e) The aggregated rebates passed on to employers. 780
(6) Reports submitted by pharmacy benefit managers and PSAOs 781
under this section may not disclose the identity of a specific 782
health benefit plan or enrollee, the identity of a drug 783
manufacturer, the prices charged for specific drugs or classes of 784
drugs, or the amount of any rebates or fees provided for specific 785
drugs or classes of drugs. 786
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(7) On or before October 1st of each year, each health 787
insurer shall submit a report to the board. The report must 788
contain the following information for the previous two (2) 789
calendar years: 790
(a) Names of the twenty-five (25) most frequently 791
prescribed drugs across all plans; 792
(b) Names of the twenty-five (25) prescription drugs 793
dispensed with the highest dollar spent in terms of gross revenue; 794
(c) Percent of increase in annual net spending for 795
prescription drugs across all plans; 796
(d) Percent of increase in premiums which is 797
attributable to prescription drugs across all plans; 798
(e) Percentage of specialty drugs with utilization 799
management requirements across all plans; and 800
(f) Premium reductions attributable to specialty drug 801
utilization management. 802
(8) A report submitted by a health insurer may not disclose 803
the identity of a specific health benefit plan or the prices 804
charged for specific prescription drugs or classes of prescription 805
drugs. 806
SECTION 11. The following shall be codified as Section 807
73-21-167, Mississippi Code of 1972: 808
73-21-167. (1) The board shall develop a website to publish 809
information the board receives under this chapter. The board 810
shall make the website available on the board's website with a 811
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dedicated link prominently displayed on the home page, or by a 812
separate, easily identifiable internet address. 813
(2) Within sixty (60) days of receipt of reported 814
information under this chapter, the board shall publish the 815
reported information on the website developed under this section. 816
The information the board publishes may not disclose or tend to 817
disclose trade secrets, proprietary, commercial, financial or 818
confidential information of any pharmacy, pharmacy benefit 819
manager, PSAO, drug wholesaler or hospital. 820
(3) The board may adopt rules to implement this chapter. 821
The board shall develop forms that must be used for reporting 822
required under this chapter. The board may contract for services 823
to implement this chapter. 824
(4) A report received by the board shall not be subject to 825
the provisions of the federal Freedom of Information Act or the 826
Mississippi Public Records Act and shall not be released by the 827
board unless subject to an order from a court of competent 828
jurisdiction. The board shall destroy or delete or cause to be 829
destroyed or deleted all such information thirty (30) days after 830
the board determines that the information is no longer necessary 831
or useful. 832
(5) This section shall stand repealed on June 30, 2028. 833
SECTION 12. The following shall be codified as Section 834
73-21-169, Mississippi Code of 1972: 835
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73-21-169. (1) Pharmacy benefit managers and PSAOs shall 836
also identify to the board any ownership affiliation of any kind 837
with any pharmacy which, either directly or indirectly, through 838
one or more intermediaries: 839
(a) Has an investment or ownership interest in a 840
pharmacy benefit manager or PSAO holding a certificate of 841
authority; 842
(b) Shares common ownership with a pharmacy benefit 843
manager or PSAO holding a certificate of authority in this state; 844
or 845
(c) Has an investor or a holder of an ownership 846
interest which is a pharmacy benefit manager or PSAO holding a 847
certificate of authority issued in this state. 848
(2) A pharmacy benefit manager or PSAO shall report any 849
change in information required by this act to the board in writing 850
within sixty (60) days after the change occurs. 851
SECTION 13. (1) There is hereby created the Mississippi 852
Independent Pharmacist Reimbursement Assistance Grant Program 853
("the program"), which shall be administered by the Mississippi 854
Board of Pharmacy. The purpose of the program is to provide 855
financial assistance to independent community pharmacies located 856
in Mississippi that experience sustained reimbursement pressures, 857
increased operational costs, or other economic challenges that 858
threaten continued access to pharmacy services in underserved 859
areas. 860
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(2) For purposes of this section: 861
(a) "Independent pharmacy" means a pharmacy licensed by 862
the Mississippi Board of Pharmacy that is privately owned, has 863
fewer than five (5) locations under common ownership, and is not 864
owned, controlled or affiliated with a pharmacy benefit manager, 865
health insurer, chain pharmacy or publicly traded corporation. 866
(b) "Eligible costs" include, but are not limited to, 867
reimbursement shortfalls, staffing expenses, technology upgrades, 868
patient care services, workflow modernization, rural delivery 869
expansion, inventory carrying costs and other expenses approved by 870
the board. 871
(c) "Board" means the Mississippi Board of Pharmacy. 872
(3) An independent pharmacy may apply for reimbursement 873
assistance under this section if it: 874
(a) Maintains active licensure in good standing with 875
the board; 876
(b) Has operated in Mississippi for at least twelve 877
(12) consecutive months prior to application; 878
(c) Demonstrates financial hardship or reimbursement 879
inadequacy through documentation required by the board; and 880
(d) Provides pharmacy services to Medicaid 881
beneficiaries, Medicare beneficiaries or patients in rural or 882
medically underserved areas, as defined by the board. 883
(4) Grant awards shall be subject to available funding. The 884
board may award grants on an annual basis. Each eligible pharmacy 885
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may receive up to an amount established annually by the board, 886
based on available appropriations. Grants may be prorated among 887
eligible applicants if requests exceed available funds. Grant 888
funds shall not be used to replace or duplicate funding provided 889
by federal programs or private settlements, but may supplement 890
such funds. 891
(5) The board shall establish an application process, 892
required documentation, timelines and evaluation standards. The 893
board shall consider factors such as financial hardship, 894
geographic access needs, patient volume and the availability of 895
pharmacy services in the applicant's community. The board may 896
require reporting on how grant funds are used and may audit 897
recipients to ensure compliance. 898
(6) The board shall promulgate rules and regulations 899
necessary to implement and administer the program, including 900
application criteria, award methodologies, documentation 901
requirements, allowable uses, reporting obligations and 902
enforcement provisions. 903
(7) The program shall be funded through annual 904
appropriations of the Legislature, grants, donations or other 905
funds made available to the board for this purpose. Grant funds 906
shall be deposited into a special fund created in the State 907
Treasury, known as the Independent Pharmacist Reimbursement 908
Assistance Fund, which shall be used solely for administering and 909
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awarding grants under this section. The fund shall be subject to 910
appropriation by the Legislature. 911
(8) The board shall submit an annual report to the Chairmen 912
of the Senate and House Public Health Committees, detailing 913
program participation, geographic distribution of awards, 914
financial data, and the impact of the program on pharmacy access 915
in Mississippi. 916
SECTION 14. (1) Nothing in this act shall be construed to 917
impose a fiduciary duty on a pharmacy benefit manager or health 918
insurer that is inconsistent with federal law. 919
(2) Nothing in this act shall be construed to prohibit a 920
health benefit plan or plan sponsor from designing or 921
administering formularies, benefit tiers, pharmacy networks, 922
utilization management programs, or cost-sharing arrangements for 923
the purpose of controlling costs and improving clinical outcomes, 924
provided such designs comply with applicable state and federal 925
law. 926
(3) Nothing in this act shall be construed to require a 927
health benefit plan or plan sponsor to include all willing 928
pharmacies in a preferred or limited network; however, a pharmacy 929
that is willing and able to meet the disclosed reimbursement 930
terms, cost-sharing arrangements, delivery capabilities, and 931
clinically appropriate service or specialty standards applicable 932
to such network shall not be excluded solely on the basis of 933
ownership status or corporate affiliation. 934
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ST: Pharmacy benefit managers; revise
provisions related to.
(4) Differences in scale, geographic coverage, delivery 935
models, pricing structures, and clinical capabilities may affect a 936
pharmacy's ability to meet network participation standards, and 937
differences do not constitute unlawful discrimination. 938
SECTION 15. This act shall take effect and be in force from 939
and after July 1, 2026. 940