Modifies provisions relating to pharmacy benefits managers

SECOND REGULAR SESSION
HOUSE COMMITTEE SUBSTITUTE FOR
HOUSE BILL NOS. 1850 & 1975
103RD GENERAL ASSEMBL Y
5331H.03C JOSEPH ENGLER, Chief Clerk
AN ACT
T o repeal sections 338.600, 376.387, and 376.388, RSMo, and to enact in lieu thereof four
new sections relating to pharmacy benefits managers.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Sections 338.600, 376.387, and 376.388, RSMo, are repealed and four
2 new sections enacted in lieu thereof, to be known as sections 338.600, 376.388, 376.394, and
3 376.399, to read as follows:
338.600. 1. As used in this section, the following terms shall mean:
2 (1) "Audit", any rev iew , inspection, investigation, examination, or analysis
3 conducted by a pharmacy benefits manager (PBM) or its r epresent ative of a pharmacy's
4 r ecords, claims, practices, or compliance with contractual obligations or legal
5 r equir ements, which may res ult in recoup ment, repay ment demand, chargeback,
6 penalty , or other financial adjustment. Routine verification or inquiry r egarding claim
7 elements or documentation shall not constitute an audit; however , no r ecoupment,
8 r epayment demand, chargeback, penalty , or financial adjustment shall be based upon or
9 initiated thr ough such inquiry unless the inquiry is converted to an audit and conducted
10 in compliance with the requ irem ents of this section;
11 (2) "Entity", a managed car e company , insurance company , or third-party
12 payer , or r epresent ative of a managed care company , insurance company , or third-party
13 payer , or a pharmacy benefits manager or a subcontractor of a pharmacy benefits
14 manager .
15 2. Notwithstanding any other provision of law to the contrary , when an audit of the
16 records of a pharmacy licensed in this state is conducted by [ a managed care company ,
EXPLANA TION — Matter enclosed in bold-faced brackets [thus] in the above bill is not enacted and is
intended to be omitted from the law . Matter in bold-face type in the above bill is proposed language.
17 insurance company , third-party payor , or ] any entity [ that represents such companies or
18 groups ], such audit shall be conducted in accordance with the following:
19 (1) The entity conducting the initial on-site audit shall provide the pharmacy with
20 notice at least [ one week ] fourteen days prior to conducting the initial on-site audit for each
21 audit cycle and shall specify specific pr escriptions to be audited, which may include the
22 final two digits of the pr escription numbers. The notice r equir ed under this subsection
23 shall be in writing and shall be sent by means that allow tracking of delivery to the
24 pharmacist or pharmacy not later than the fourteenth day befor e the date on which the
25 on-site audit is scheduled to occur . A pharmacy benefits manager is not requi red to
26 pr ovide notice before conducting an audit if, after revie wing claims data, written or oral
27 statements of pharmacy staff, wholesalers, or other investigative information, including
28 patient ref errals, the plan issuer or pharmacy benefits manager suspects the pharmacist
29 or pharmacy subject to the audit committed fraud or made an intentional
3 0 misr epr esentation rela ted to the pharmacy business, which cause and suspicion shall
31 be disclosed to the pharmacy upon initiation of the audit ;
32 (2) Any audit which involves clinical judgment shall be conducted by or in
33 consultation with a [ licensed ] pharmacist licensed by the Missouri board of pharmacy , and
34 such pharmacist shall be made available to the audited pharmacy to discuss clinical
35 rationale and Missouri legal req uirements ;
36 (3) Any clerical error , record-keeping error , typographical error , or scrivener's error
37 regarding a required document or record shall not constitute fraud or grounds for recoupment,
38 so long as the prescription was otherwise legally dispensed and the claim was otherwise
39 materially correct; except that, such claims may be otherwise subject to recoupment of
40 overpayments or payment of any discovered underpayment. No claim arising under this
41 subdivision shall be subject to criminal penalties without proof of intent to commit fraud .
42 The pharmacy shall have the right to submit amended claims within thirty days of the
43 discovery of an err or to corr ect clerical or re cord-keeping err ors in lieu of r ecoupment if
44 the pr escription was dispensed according to r equir ements set forth in state or federal
45 law ;
46 (4) A pharmacy may use the records of a hospital, physician, or other authorized
47 practitioner of the healing arts involving drugs or medicinal supplies written or transmitted by
48 any means of communication for purposes of validating the pharmacy record with respect to
49 orders or refills of a legend or narcotic drug. Electronically stored images of prescriptions,
50 electronically created annotations and other related supporting documentation shall be
51 considered valid prescription records. Hard copy and electronic signature logs that indicate
52 the delivery of pharmacy services shall be considered valid proof of receipt of such services
53 by a program enrollee;
HCS HBs 1850 & 1975 2
54 (5) A finding of an overpayment or underpayment may be a projection based on the
55 number of patients served and having a similar diagnosis or on the number of similar orders
56 or refills for similar drugs; except that, recoupment of claims shall be based on the actual
57 overpayment or underpayment unless the projection for overpayment or underpayment is part
58 of a settlement as agreed to by the pharmacy;
59 (6) Each pharmacy shall be audited under the same standards and parameters as other
60 pharmacies audited by the entity;
61 (7) A pharmacy shall be allowed at least thirty days following receipt of the
62 preliminary audit report in which to produce documentation to address any discrepancy found
63 during an audit;
64 (8) An audit shall be limited to forty unique prescrip tions, with a maximum of
65 two hundred separately adjudicated claims, that have been randomly selected, and such
66 randomness shall be r eflected by auditing similar types of pre scriptions as are
67 collectively adjudicated. The following pro visions shall apply:
68 (a) If an audit rev eals the necessity for a r eview of additional claims, the audit
69 shall be conducted on site;
70 (b) An entity shall not initiate an audit of a pharmacy mor e than two times in a
71 calendar year; such audit of pharmacy r ecords includes any prescrip tion information
72 r equest by an auditing entity that could res ult in re coupment; and
73 (c) The list of the claims subject to an on-site audit shall be provi ded in the notice
74 under paragraph (a) of this subdivision to the pharmacist or pharmacy and shall
75 identify the claims only by the pre scription numbers or a date range for pr escriptions
76 subject to the audit. The last two digits of the pr escription numbers pr ovided may be
77 omitted;
78 (9) A recoup ment shall not be based on a req uirement that a pharmacy or
79 pharmacist perform a pro fessional duty in addition to or exceeding pr ofessional duties
80 pr escribed by the Missouri board of pharmacy;
81 (10) Recoupment shall only occur following the corr ection of a claim and shall be
82 limited to amounts adjudicated by a pharmacy benefits manager;
83 (1 1) Except for MO HealthNet claims, appr oval of drug, pr escriber , or patient
84 eligibility upon adjudication of a claim shall not be reversed unless the pharmacy or
85 pharmacist obtained the adjudication by fraud, waste, or abuse, a misr epresent ation of
86 claim elements, or claims that wer e not pr operly render ed or billed by a pharmacy or
87 pharmacist, or otherwise in accordance with state pharmacy audit laws. The following
88 pr ovisions shall apply:
HCS HBs 1850 & 1975 3
89 (a) This subdivision does not pr eclude a pharmacy benefits manager fr om
90 engaging in claims r econciliation activities r elating to brand effective rates and generic
91 effective rates if:
92 a. They ar e identified and agreed to in contract; and
93 b. The activities do not res ult in a ret roac tive red uction or re coupment of
94 payment to the pharmacist or pharmacy for a pr eviously adjudicated cover ed claim;
95 and
96 (b) A pharmacy benefits manager shall not charge a pharmacy or pharmacist a
97 fee relat ing to the adjudication of a claim;
98 (12) Any entity conducting an audit shall not be compensated, nor shall any of its
99 employees be compensated, dire ctly or indirectl y , based on any amounts r ecouped;
100 (13) An entity shall not charge a fee for conducting an on-site or a desk audit
101 unless ther e is a finding of actual fraud;
102 (14) The period covered by the audit shall not exceed a two-year period beginning
103 [ two years prior to the initial date of the on-site portion of the audit unless otherwise provided
104 by contractual agreement or if ] the date the claim was submitted for payment unless there
105 has been a previous finding of fraud or as otherwise provided by state or federal law;
106 [ (9) ] (15) An audit shall not be initiated or scheduled during the first [ three ] five
107 business days of any month due to the high volume of prescriptions filled during such time
108 unless otherwise consented to by the pharmacy;
109 [ (10) ] (16) The preliminary audit report shall be delivered to the pharmacy within one
110 hundred twenty days after conclusion of the audit, with reasonable extensions permitted. A
111 final audit report shall be delivered to the pharmacy within six months of receipt by the
112 pharmacy of the preliminary audit report or final appeal, as provided for in subsection [ 3 ] 4 of
113 this section, whichever is later . Audit rep orts not deliver ed to the pharmacy in this
114 timeline shall be deemed to have no discrep ancies and no recoup ment shall be made ;
115 [ (1 1) ] (17) Notwithstanding any other provision in this subsection, the entity
116 conducting the audit shall not use the accounting practice of extrapolation in calculating
117 recoupments or penalties for audits, except as otherwise authorized under subdivision (5) of
118 this subsection ;
119 (18) The days' supply for unit-of-use items, such as topicals, drop s, vials, and
120 inhalants, shall not be limited beyond manufactur er recomm endations;
121 (19) If the only commer cially available package size exceeds an entity's
122 maximum days' supply , the dispensing of such package size shall be accepted by the
123 entity and shall not be the basis for recou pment;
HCS HBs 1850 & 1975 4
124 (20) If the only commer cially available package size exceeds an entity's
125 maximum days' supply and the entity accepts the r efill of such prescription , the entity
126 shall not recou p such claim as an early ref ill;
127 (21) The failure of a pharmacy to collect a co-payment shall not be the basis for
128 r ecoupment if the pharmacy provi des documentation of billing of the claim and a
129 r easonable attempt to collect the co-payment; and
130 (22) In a wholesale invoice audit conducted by an entity:
131 (a) An entity shall not audit the claims of another entity;
132 (b) The following shall not form the basis for recou pment:
133 a. The National Drug Code for the dispensed drug is in a quantity that is a sub-
134 unit or multiple of the pur chased drug as r eflected on a supporting wholesale invoice;
135 b. The corr ect quantity dispensed is ref lected on the audited pharmacy claim; or
136 c. The drug dispensed by the pharmacy on an audited pharmacy claim is
137 identical to the str ength and dosage form of the drug pur chased;
138 (c) The entity shall accept as evidence:
139 a. Supplier invoices issued prior to the date of dispensing the drug underlying
140 the audited claim;
141 b. Invoices fr om any supplier authorized by law to transfer ownership of the
142 drug acquired by the audited pharmacy;
143 c. Copies of supplier invoices in the possession of the audited pharmacy; and
144 d. Reports req uired by any state board or agency; and
145 (d) W ithin five business days of a requ est by the audited pharmacy , the entity
146 shall pr ovide supporting documentation pr ovided to the entity by the audited
14 7 pharmacy's suppliers .
148 [ 2. ] 3. Recoupments of any disputed moneys shall only occur after final internal
149 disposition of the audit, including the appeals process set forth in subsection [ 3 ] 4 of this
150 section. Should the identified discrepancy for an individual audit exceed twenty-five
151 thousand dollars, future payments to the pharmacy in excess of twenty-five thousand dollars
152 may be withheld pending finalization of the audit.
153 [ 3. ] 4. Each entity conducting an audit shall establish an appeals process, lasting no
154 longer than six months, under which a licensed pharmacy may appeal an unfavorable
155 preliminary audit report to the entity . If, following such appeal, the entity finds that an
156 unfavorable audit report or any portion thereof is unsubstantiated, the entity shall dismiss the
157 audit report or such portion without the necessity of any further proceedings.
158 [ 4. ] 5. Each entity conducting an audit shall provide a copy of the final audit report,
159 after completion of any appeal process, to the plan sponsor . Such r eport shall include the
160 total amount of rec oupment r eturned to the plan sponsor , if any .
HCS HBs 1850 & 1975 5
161 [ 5. ] 6. This section shall not apply to any investigative audit that involves probable
162 fraud, willful misrepresentation, or abuse.
163 [ 6. ] 7. This section shall not apply to any audit conducted as part of any inspection or
164 investigation conducted by any governmental entity or law enforcement agency .
376.388. 1. As used in this section, unless the context requires otherwise, the
2 following terms shall mean:
3 (1) "Affiliated pharmacy", a pharmacy that directly or indir ectly , thr ough one
4 or mor e intermediaries, owns or contr ols, is owned or controlled by , or is under common
5 ownership or control with a pharmacy benefits manager;
6 (2) "Contracted pharmacy" [ or "pharmacy" ], a pharmacy located in Missouri
7 participating in the network of a pharmacy benefits manager through a direct or indirect
8 contract;
9 [ (2) ] (3) "Health carrier", an entity subject to the insurance laws and regulations of
10 this state that contracts or offer s to contract to provide, deliver , arrange for , pay for , or
11 reimburse any of the costs of health care services, including a sickness and accident insurance
12 company , a health maintenance or ganization, a nonprofit hospital and health service
13 corporation, or any other entity providing a plan of health insurance, health benefits, or health
14 services, except that such plan shall not include any coverage pursuant to a liability insurance
15 policy , workers' compensation insurance policy , or medical payments insurance issued as a
16 supplement to a liability policy;
17 [ (3) ] (4) "Maximum allowable cost", the per -unit amount that a pharmacy benefits
18 manager reimburses a pharmacist for a prescription drug, excluding a dispensing or
19 professional fee;
20 [ (4) ] (5) "Maximum allowable cost list" or "MAC list", a listing of drug products that
21 meet the standard described in this section;
22 [ (5) ] (6) "Pharmacy", as such term is defined in chapter 338;
23 [ (6) ] (7) "Pharmacy benefits manager", an entity that contracts with pharmacies on
24 behalf of health carriers [ or any health plan sponsored by the state or a political subdivision of
25 the state ] or health benefit plans to prov ide prescription drug and pharmacist services .
26 2. Upon each contract execution or renewal between a pharmacy benefits manager
27 and a pharmacy or between a pharmacy benefits manager and a pharmacy's contracting
28 representative or agent, such as a pharmacy services administrative or ganization, a pharmacy
29 benefits manager shall, with respect to such contract or renewal:
30 (1) Include in such contract or renewal the sources utilized to determine maximum
31 allowable cost and update such pricing information at least every seven days; and
32 (2) Maintain a procedure to eliminate products from the maximum allowable cost list
33 of drugs subject to such pricing or modify maximum allowable cost pricing at least every
HCS HBs 1850 & 1975 6
34 seven days, if such drugs do not meet the standards and requirements of this section, in order
35 to remain consistent with pricing changes in the marketplace.
36 3. A pharmacy benefits manager shall reimburse pharmacies for drugs subject to
37 maximum allowable cost pricing that has been updated to reflect market pricing at least every
38 seven days as set forth under subdivision (1) of subsection 2 of this section.
39 4. A pharmacy benefits manager shall not place a drug on a maximum allowable cost
40 list unless there are at least two therapeutically equivalent multisource generic drugs, or at
41 least one generic drug available from at least one manufacturer , generally available for
42 purchase by network pharmacies from national or regional wholesalers.
43 5. All contracts between a pharmacy benefits manager and a contracted pharmacy or
44 between a pharmacy benefits manager and a pharmacy's contracting representative or agent,
45 such as a pharmacy services administrative or ganization, shall include a process to internally
46 appeal, investigate, and resolve disputes regarding maximum allowable cost pricing. The
47 process shall include the following:
48 (1) The right to appeal shall be limited to fourteen calendar days following the
49 reimbursement of the initial claim; and
50 (2) A requirement that the pharmacy benefits manager shall respond to an appeal
51 described in this subsection no later than fourteen calendar days after the date the appeal was
52 received by such pharmacy benefits manager .
53 6. For appeals that are denied, the pharmacy benefits manager shall provide the
54 reason for the denial and identify the national drug code of a drug product that may be
55 purchased by contracted pharmacies at a price at or below the maximum allowable cost and,
56 when applicable, may be substituted lawfully .
57 7. If the appeal is successful, the pharmacy benefits manager shall:
58 (1) Adjust the maximum allowable cost price that is the subject of the appeal ef fective
59 on the day after the date the appeal is decided;
60 (2) Apply the adjusted maximum allowable cost price to all similarly situated
61 pharmacies as determined by the pharmacy benefits manager; and
62 (3) Allow the pharmacy that succeeded in the appeal to reverse and rebill the
63 pharmacy benefits claim giving rise to the appeal.
64 8. Appeals shall be upheld if:
65 (1) The pharmacy being reimbursed for the drug subject to the maximum allowable
66 cost pricing in question was not reimbursed as required under subsection 3 of this section; or
67 (2) The drug subject to the maximum allowable cost pricing in question does not meet
68 the requirements set forth under subsection 4 of this section.
69 9. A pharmacy benefits manager shall provi de plan sponsors with such plan
70 sponsor's pharmacy claims data as r easonably r equested by a plan sponsor .
HCS HBs 1850 & 1975 7
71 10. The pharmacy benefits manager or plan sponsor shall provi de the plan
72 sponsor and department of commer ce and insurance documentation of any benefit
73 design that encourages or r equir es enr ollees to fill pre scriptions at affiliated pharmacies.
74 1 1. A pharmacy benefits manager shall exer cise good faith and fair dealing in
75 the administration of pharmacy benefits and shall ensur e that any conflicts of inter est
76 that may clinically or financially impact cover ed patients or the health benefit plan
77 sponsor in a negative manner are disclosed.
78 12. All disclosur es req uired under this section shall be pr ovided to the plan
79 sponsor or its authorized agent in a universal manner .
80 13. If a pharmacy benefits manager or health plan has an affiliated pharmacy or
81 a pharmacy under common ownership, the pharmacy benefits manager shall disclose to
82 the plan sponsor and the department of commer ce and insurance:
83 (1) The amount charged per dosage unit to the affiliated pharmacy; and
84 (2) The median amount charged per dosage unit at nonaffiliated, in-network
85 pharmacies.
86 14. The department of commer ce and insurance may audit pharmacy benefits
87 managers to ensur e compliance with this section.
376.394 . 1. As used in this section, the following terms shall mean:
2 (1) "Critical-access care pharmacy", a Missouri-domiciled pharmacy with a
3 physical location in the state of Missouri that employs fewer than five hundr ed
4 employees acr oss common ownership and that is:
5 (a) Located in:
6 a. A county or city with fewer than fifty thousand r esidents; or
7 b. A county or city with fifty thousand or mor e r esidents and in an area within
8 Missouri that is designated as a Primary Car e or Mental Health Health Pr ofessional
9 Shortage Area (HPSA) or a Medically Underserved Are a by the Health Resour ces and
10 Services Administration (HRSA), an agency of the U.S. Department of Health and
11 Human Services; or
12 (b) Any essential r etail pharmacy as defined in Section 1860D-42 of the Social
13 Security Act, 42 U.S.C. Section 1395w-152, as amended by Pub. L. 1 19-75;
14 (2) "Similarly situated", a critical-access care pharmacy:
15 (a) That is in any of the pharmacy benefits manager's networks;
16 (b) That pur chases the particular drug or medical prod uct or device to which
17 the finding applies fro m the same pharmaceutical wholesaler as the pharmacy that
18 pr evailed in the appeal; and
19 (c) T o which the pharmacy benefits manager also applies the challenged rate of
20 r eimbursement or actual cost.
HCS HBs 1850 & 1975 8
21 2. Notwithstanding any pro vision of law to the contrary , a pharmacy benefits
22 manager shall not rei mburse a critical-access care pharmacy for a pr escription drug or
23 device an amount that is less than the actual cost to that pharmacy for the pr escription
24 drug or device plus a pr ofessional dispensing fee of ten dollars and fifty cents per claim.
25 The following provi sions shall apply:
26 (1) A pharmacy benefits manager shall establish a pr ocess for a pharmacy to
27 appeal a reim bursement for failing to pay at least the actual cost and dispensing fee to
28 the critical-access car e pharmacy for the prescription drug or device and shall permit a
29 critical-access car e pharmacy or its designated agent to file an appeal using the standard
30 appeal form described in this section;
31 (2) If a critical-access car e pharmacy chooses to contest a rei mbursement for
32 failing to pay at least the actual cost the critical-access care pharmacy incurr ed for a
33 particular drug or medical pro duct or device, the critical-access car e pharmacy has the
34 right to designate a pharmacy services administrative organization or other agent to file
35 and handle its appeal; and
36 (3) The department of commer ce and insurance shall cre ate and make available
37 to pharmacy benefits managers and cover ed entities a standard form to be used by a
38 critical-access car e pharmacy or its designated agent to file an appeal pursuant to this
39 subsection with a pharmacy benefits manager or covered entity .
40 3. If a critical-access car e pharmacy or agent acting on behalf of a critical-access
41 car e pharmacy pre vails in an appeal pr ovided for in this section, the pharmacy benefits
42 manager or cover ed entity shall, within seven business days after notice of the appeal is
43 r eceived by the pharmacy benefits manager or covered entity:
44 (1) Make the necessary change to the challenged rate of r eimbursement or actual
45 cost;
46 (2) If the pr oduct involved in the appeal is a drug, pr ovide to the critical-access
47 car e pharmacy or agent the National Drug Code number for the drug on which the
48 change is based;
49 (3) Permit the challenging critical-access car e pharmacy to rev erse and rebil l the
50 claim upon which the appeal is based;
51 (4) Pay or waive the cost of any transaction fee r equir ed to reverse and rebil l the
52 claim;
53 (5) Reimburse the critical-access car e pharmacy at least in an amount equal to
54 the critical-access car e pharmacy's actual cost for the prescrip tion drug or device; and
55 (6) Apply the findings fr om the appeal as to the rate of reim bursement and
56 actual cost for the particular drug or medical pr oduct or device to other similarly
57 situated critical-access care pharmacies.
HCS HBs 1850 & 1975 9
58 4. It is a violation of this section if, after an appeal in which a pharmacy or agent
59 acting on behalf of a critical-access care pharmacy prevai ls, a pharmacy benefits
60 manager or cover ed entity fails to rei mburse the critical-access care pharmacy at least
61 actual cost.
62 5. If a critical-access car e pharmacy or agent acting on behalf of a critical-access
63 car e pharmacy loses or is denied an appeal prov ided for in this section, the following
64 pr ovisions shall apply:
65 (1) If the pr oduct associated with the National Drug Code number or unique
66 device identifier is available at a cost that is less than the challenged rate of
67 r eimbursement fr om a pharmaceutical wholesaler in this state, the pharmacy benefits
68 manager or cover ed entity shall, within seven business days after notice of the appeal is
69 r eceived by the pharmacy benefits manager or cover ed entity , pr ovide the appealing
70 critical-access car e pharmacy or agent with:
71 (a) The name of the national or regio nal pharmaceutical wholesalers operating
72 in this state that have the particular drug or medical pr oduct or device curr ently in
73 stock at a price that is less than the amount of the challenged rate of r eimbursement;
74 and
75 (b) If the pr oduct involved in the appeal is a drug, the National Drug Code
76 number for the drug; or
77 (c) If the pr oduct involved is a medical device, the unique device identifier for
78 the device; and
79 (2) If the pr oduct associated with the National Drug Code number or unique
80 device identifier is not available at a cost that is less than the challenged rate of
81 r eimbursement fr om the pharmaceutical wholesaler fr om whom the critical-access car e
82 pharmacy pur chases the majority of prescription pharmaceutical pr oducts for res ale,
83 the pharmacy benefits manager shall adjust the challenged rate of rei mbursement to an
84 amount equal to or great er than the appealing critical-access care pharmacy's actual
85 cost and permit the critical-access care pharmacy to reverse and r ebill each claim
86 affected by the inability to pr ocure the pharmaceutical prod uct at a cost that is equal to
87 or less than the pr eviously challenged rate of re imbursement. The pharmacy benefits
88 manager shall pay or waive the cost of any transaction fee r equir ed to reverse and rebi ll
89 the claim.
90 6. The department of commer ce and insurance shall enforce this section.
376.399 . 1. Health benefit plans beginning on or after January 1, 2027, shall
2 comply with H.R. 7148, the Consolidated Appr opriations Act, 2026.
3 2. For plan years beginning on or after January 1, 2027, no contract or
4 arrangement or ren ewal or extension of a contract or arrangement, enter ed into on or
HCS HBs 1850 & 1975 10
5 after January 1, 2027, for services between a cover ed plan and a covere d service
6 pr ovider , or between a sponsor of a cover ed plan and a cover ed service pro vider ,
7 thr ough a health insurance issuer offering gr oup health insurance coverage, a third-
8 party administrator , an entity pr oviding pharmacy benefit management services, or
9 other entity , for pharmacy benefit management services, is reas onable within the
10 meaning of this section unless such entity pr oviding pharmacy benefit management
11 services:
12 (1) Remits one hundr ed per cent of r ebates, fees, alternative discounts, and other
13 r emuneration received fro m any applicable entity that ar e relat ed to utilization of drugs
14 or drug spending under such health plan or health insurance coverage, to the grou p
15 health plan or , in the case of a health insurance issuer offering gr oup health insurance
16 coverage in connection with a gr oup health plan, to the health insurance issuer offering
17 gr oup health insurance coverage on behalf of the plan; and
18 (2) Does not enter into any contract for pharmacy benefit management services
19 on behalf of such a plan or coverage with an applicable entity unless one hundr ed
20 per cent of rebates , fees, alternative discounts, and other rem uneration received under
21 such contract that ar e r elated to the utilization of drugs or drug spending under such
22 gr oup health plan or health insurance coverage ar e rem itted to the gr oup health plan or ,
23 in the case of a health insurance issuer offering grou p health insurance coverage in
24 connection with a grou p health plan, to the health insurance issuer on behalf of the plan
25 by the entity pro viding pharmacy benefit management services.
26
27 Nothing in this subsection shall be construed to affect the term of a contract or
28 arrangement, as in effect on January 1, 2027, except that such subsection shall apply to
29 any rene wal or extension of such a contract or arrangement enter ed into on or after
30 such effective date, as so described.
31 3. W ith r espect to such r ebates, fees, alternative discounts, and other
32 r emuneration, the reba tes, fees, alternative discounts, and other rem uneration under
33 this section shall be rem itted:
34 (1) On a quarterly basis, to the gr oup health plan or , in the case of a health
35 insurance issuer offering gr oup health insurance coverage in connection with a grou p
36 health plan, to the grou p health insurance issuer on behalf of the plan, not later than
37 ninety days after the end of each quarter; or
38 (2) In the case of an underpayment in a rem ittance for a prior quarter , as soon as
39 practicable, but not later than ninety days after notice of the underpayment is first
40 given;
HCS HBs 1850 & 1975 1 1
41 (3) Fully disclosed and enumerated to the gr oup health plan or health insurance
42 issuer; and
43 (4) Returned to the cover ed service provi der for pharmacy benefit management
44 services on behalf of the gro up health plan if any audit by a plan sponsor , issuer , or third
45 party designated by a plan sponsor indicates that the amounts received ar e in excess of
46 corr ect amounts after such amounts have been paid to the group health plan, in the
47 amount of such excess.
48 4. The department of commerce and insurance shall enforce this section and
49 shall have the right to any information described in this section fro m any pharmacy
50 benefits manager under investigation individually or in aggr egate at the department's
51 r equest.
[ 376.387 . 1. For purposes of this section, the following terms shall
2 mean:
3 (1) "Covered person", the same meaning as such term is defined in
4 section 376.1257;
5 (2) "Health benefit plan", the same meaning as such term is defined in
6 section 376.1350;
7 (3) "Health carrier" or "carrier", the same meaning as such term is
8 defined in section 376.1350;
9 (4) "Pharmacy", the same meaning as such term is defined in chapter
10 338;
11 (5) "Pharmacy benefits manager", the same meaning as such term is
12 defined in section 376.388.
13 2. No pharmacy benefits manager shall include a provision in a
14 contract entered into or modified on or after August 28, 2018, with a pharmacy
15 or pharmacist that requires a covered person to make a payment for a
16 prescription drug at the point of sale in an amount that exceeds the lesser of:
17 (1) The copayment amount as required under the health benefit plan;
18 or
19 (2) The amount an individual would pay for a prescription if that
20 individual paid with cash.
21 3. A pharmacy or pharmacist shall have the right to provide to a
22 covered person information regarding the amount of the covered person's cost
23 share for a prescription drug, the covered person's cost of an alternative drug,
24 and the covered person's cost of the drug without adjudicating the claim
25 through the pharmacy benefits manager . Neither a pharmacy nor a pharmacist
26 shall be proscribed by a pharmacy benefits manager from discussing any such
27 information or from selling a more af fordable alternative to the covered
28 person.
29 4. No pharmacy benefits manager shall, directly or indirectly , char ge
30 or hold a pharmacist or pharmacy responsible for any fee amount related to a
31 claim that is not known at the time of the claim's adjudication, unless the
32 amount is a result of improperly paid claims or char ges for administering a
33 health benefit plan.
HCS HBs 1850 & 1975 12
34 5. This section shall not apply with respect to claims under Medicare
35 Part D, or any other plan administered or regulated solely under federal law ,
36 and to the extent this section may be preempted under the Employee
37 Retirement Income Security Act of 1974 for self-funded employer -sponsored
38 health benefit plans.
39 6. A pharmacy benefits manager shall notify in writing any health
40 carrier with which it contracts if the pharmacy benefits manager has a conflict
41 of interest, any commonality of ownership, or any other relationship, financial
42 or otherwise, between the pharmacy benefits manager and any other health
43 carrier with which the pharmacy benefits manager contracts.
44 7. The department of commerce and insurance shall enforce this
45 section. ]
✔
HCS HBs 1850 & 1975 13