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EXPLANATION-Matter enclosed in bold-faced brackets [thus] in this bill is not enacted
and is intended to be omitted in the law.
SECOND REGULAR SESSION
SENATE COMMITTEE SUBSTITUTE FOR
SENATE BILLS NOS. 984 & 968
103RD GENERAL ASSEMBLY
5297S.07C KRISTINA MARTIN, Secretary
AN ACT
To repeal sections 338.600 and 376.387, 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 and 376.387, RSMo, are 1
repealed and four new sections enacted in lieu thereof, to be 2
known as sections 338.600, 376.387, 376.394, and 376.399, to 3
read as follows:4
338.600. 1. As used in this section, the following 1
terms shall mean: 2
(1) "Audit", any review, inspection, investigation, 3
examination, or analysis conducted by a pharmacy benefits 4
manager (PBM) or its representative of a pharmacy's records, 5
claims, practices, or compliance with contractual 6
obligations or legal requirements, which may result in 7
recoupment, repayment demand, chargeback, penalty, or other 8
financial adjustment. Routine verification or inquiry 9
regarding claim elements or documentation shall not 10
constitute an audit; however, no recoupment, repayment 11
demand, chargeback, penalty, or financial adjustment shall 12
be based upon or initiated through such inquiry unless the 13
inquiry is converted to an audit and conducted in compliance 14
with the requirements of this section; 15
SCS SBs 984 & 968 2
(2) "Entity", a managed care company, insurance 16
company or third-party payor, or representative of a managed 17
care company, insurance company or third-party payor, or a 18
pharmacy benefits manager or a subcontractor of a pharmacy 19
benefits manager. 20
2. Notwithstanding any other provision of law to the 21
contrary, when an audit of the records of a pharmacy 22
licensed in this state is conducted by a managed care 23
company, insurance company, third-party payor, or any entity 24
that represents such companies or groups, such audit shall 25
be conducted in accordance with the following: 26
(1) The entity conducting the initial on-site audit 27
shall provide the pharmacy with notice at least [one week] 28
fourteen days prior to conducting the initial on-site audit 29
for each audit cycle and shall specify specific 30
prescriptions to be audited which may or may not include the 31
final two digits of the prescription numbers. The notice 32
required under this subsection shall be in writing and shall 33
be sent by means that allows tracking of delivery to the 34
pharmacist or pharmacy not later than the fourteenth day 35
before the date on which the on-site audit is scheduled to 36
occur. A pharmacy benefit manager is not required to 37
provide notice before conducting an audit if, after 38
reviewing claims data, written or oral statements of 39
pharmacy staff, wholesalers, or other investigative 40
information, including patient referrals, the plan issuer or 41
pharmacy benefit manager suspects the pharmacist or pharmacy 42
subject to the audit committed fraud or made an intentional 43
misrepresentation related to the pharmacy business, which 44
cause and suspicion shall be disclosed to pharmacy upon 45
initiation of the audit; 46
SCS SBs 984 & 968 3
(2) Any audit which involves clinical judgment shall 47
be conducted by or in consultation with a [licensed] 48
pharmacist licensed by the Missouri board of pharmacy, and 49
said pharmacist shall be made available to the audited 50
pharmacy to discuss clinical rationale and Missouri legal 51
requirements; 52
(3) Any clerical error, record-keeping error, 53
typographical error, or scrivener's error regarding a 54
required document or record shall not constitute fraud or 55
grounds for recoupment, so long as the prescription was 56
otherwise legally dispensed and the claim was otherwise 57
materially correct; except that, such claims may be 58
otherwise subject to recoupment of overpayments or payment 59
of any discovered underpayment. No claim arising under this 60
subdivision shall be subject to criminal penalties without 61
proof of intent to commit fraud. The pharmacy shall have 62
the right to submit amended claims within thirty days of the 63
discovery of an error to correct clerical or record keeping 64
errors in lieu of recoupment if the prescription was 65
dispensed according to requirements set forth in state or 66
federal law; 67
(4) A pharmacy may use the records of a hospital, 68
physician, or other authorized practitioner of the healing 69
arts involving drugs or medicinal supplies written or 70
transmitted by any means of communication for purposes of 71
validating the pharmacy record with respect to orders or 72
refills of a legend or narcotic drug. Electronically stored 73
images of prescriptions, electronically created annotations 74
and other related supporting documentation shall be 75
considered valid prescription records. Hard copy and 76
electronic signature logs that indicate the delivery of 77
SCS SBs 984 & 968 4
pharmacy services shall be considered valid proof of receipt 78
of such services by a program enrollee; 79
(5) A finding of an overpayment or underpayment may be 80
a projection based on the number of patients served and 81
having a similar diagnosis or on the number of similar 82
orders or refills for similar drugs; except that, recoupment 83
of claims shall be based on the actual overpayment or 84
underpayment unless the projection for overpayment or 85
underpayment is part of a settlement as agreed to by the 86
pharmacy; 87
(6) Each pharmacy shall be audited under the same 88
standards and parameters as other pharmacies audited by the 89
entity; 90
(7) A pharmacy shall be allowed at least thirty days 91
following receipt of the preliminary audit report in which 92
to produce documentation to address any discrepancy found 93
during an audit; 94
(8) An audit shall be limited to forty unique 95
prescriptions, with a maximum of two hundred separately 96
adjudicated claims, that have been randomly selected, and 97
such randomness shall be reflected by auditing a similar 98
type of prescriptions as are collectively adjudicated. 99
(a) If an audit reveals the necessity for a review of 100
additional claims, the audit shall be conducted on site. 101
(b) An entity shall not initiate an audit of a 102
pharmacy more than two times in a calendar year, unless 103
fraud is suspected as described in subdivision (1) of this 104
subsection; such audit of pharmacy records includes any 105
prescription information request by an auditing entity that 106
could result in recoupment. 107
(c) The list of the claims subject to an on-site audit 108
shall be provided in the notice under paragraph (a) of this 109
SCS SBs 984 & 968 5
subdivision to the pharmacist or pharmacy and shall identify 110
the claims only by the prescription numbers or a date range 111
for prescriptions subject to the audit. The last two digits 112
of the prescription numbers provided may be omitted; 113
(9) A recoupment shall not be based on a requirement 114
that a pharmacy or pharmacist perform a professional duty in 115
addition to or exceeding professional duties prescribed by 116
the Missouri board of pharmacy; 117
(10) Recoupment shall only occur following the 118
correction of a claim and shall be limited to amounts 119
adjudicated by a pharmacy benefits manager; 120
(11) Except for MO HealthNet claims, approval of drug, 121
prescriber, or patient eligibility upon adjudication of a 122
claim shall not be reversed unless the pharmacy or 123
pharmacist obtained the adjudication by fraud, waste, or 124
abuse, a misrepresentation of claim elements, or claims that 125
were not properly rendered or billed by a pharmacy or 126
pharmacist, or otherwise in accordance with state pharmacy 127
audit laws. 128
(a) This subdivision does not preclude a pharmacy 129
benefits manager from engaging in claims reconciliation 130
activities relating to brand effective rates and generic 131
effective rates if: 132
a. They are identified and agreed to in contract; and 133
b. The activities do not result in a retroactive 134
reduction or recoupment of payment to the pharmacist or 135
pharmacy for a previously adjudicated covered claim. 136
(b) A pharmacy benefits manager may not charge a 137
pharmacy or pharmacist a fee relating to the adjudication of 138
a claim; 139
SCS SBs 984 & 968 6
(12) Any entity conducting an audit shall not be 140
compensated, nor shall any of its employees be compensated, 141
directly or indirectly, based on any amounts recouped; 142
(13) An entity shall not charge a fee for conducting 143
an on-site or a desk audit unless there is a finding of 144
actual fraud; 145
(14) The period covered by the audit shall not exceed 146
a two-year period beginning [two years prior to the initial 147
date of the on-site portion of the audit unless otherwise 148
provided by contractual agreement or if] the date the claim 149
was submitted for payment there has been a previous finding 150
of fraud or as otherwise provided by state or federal law; 151
[(9)] (15) An audit shall not be initiated or 152
scheduled during the first [three] five business days of any 153
month due to the high volume of prescriptions filled during 154
such time unless otherwise consented to by the pharmacy; 155
[(10)] (16) The preliminary audit report shall be 156
delivered to the pharmacy within one hundred twenty days 157
after conclusion of the audit, with reasonable extensions 158
permitted. A final audit report shall be delivered to the 159
pharmacy within six months of receipt by the pharmacy of the 160
preliminary audit report or final appeal, as provided for in 161
subsection 3 of this section, whichever is later. Audit 162
reports not delivered to the pharmacy in this time line 163
shall be deemed to have no discrepancies and no recoupment 164
shall be made; 165
[(11)] (17) Notwithstanding any other provision in 166
this subsection, the entity conducting the audit shall not 167
use the accounting practice of extrapolation in calculating 168
recoupments or penalties for audits, except as otherwise 169
authorized under subdivision (5) of this subsection; 170
SCS SBs 984 & 968 7
(18) The days' supply for unit-of-use items, such as 171
topicals, drops, vials, and inhalants, shall not be limited 172
beyond manufacturer recommendations; 173
(19) If the only commercially available package size 174
exceeds an entity's maximum days' supply, the dispensing of 175
such package size shall be accepted by the entity and shall 176
not be the basis for recoupment; 177
(20) If the only commercially available package size 178
exceeds an entity's maximum days' supply and the entity 179
accepts the refill of such prescription, the entity shall 180
not recoup such claim as an early refill; 181
(21) The failure of a pharmacy to collect a copayment 182
shall not be the basis for recoupment if the pharmacy 183
provides documentation of billing of the claim and a 184
reasonable attempt to collect the copayment; and 185
(22) In a wholesale invoice audit conducted by an 186
entity: 187
(a) An entity shall not audit the claims of another 188
entity; 189
(b) The following shall not form the basis for 190
recoupment: 191
a. The national drug code for the dispensed drug is in 192
a quantity that is a sub-unit or multiple of the purchased 193
drug as reflected on a supporting wholesale invoice; 194
b. The correct quantity dispensed is reflected on the 195
audited pharmacy claim; or 196
c. The drug dispensed by the pharmacy on an audited 197
pharmacy claim is identical to the strength and dosage form 198
of the drug purchased; 199
(c) The entity shall accept as evidence: 200
a. Supplier invoices issued prior to the date of 201
dispensing the drug underlying the audited claim; 202
SCS SBs 984 & 968 8
b. Invoices from any supplier authorized by law to 203
transfer ownership of the drug acquired by the audited 204
pharmacy; 205
c. Copies of supplier invoices in the possession of 206
the audited pharmacy; and 207
d. Reports required by any state board or agency; and 208
(d) Within five business days of a request by the 209
audited pharmacy, the entity shall provide supporting 210
documentation provided to the entity by the audited 211
pharmacy's suppliers. 212
[2.] 3. Recoupments of any disputed moneys shall only 213
occur after final internal disposition of the audit, 214
including the appeals process set forth in subsection 3 of 215
this section. Should the identified discrepancy for an 216
individual audit exceed twenty-five thousand dollars, future 217
payments to the pharmacy in excess of twenty-five thousand 218
dollars may be withheld pending finalization of the audit. 219
[3.] 4. Each entity conducting an audit shall 220
establish an appeals process, lasting no longer than six 221
months, under which a licensed pharmacy may appeal an 222
unfavorable preliminary audit report to the entity. If, 223
following such appeal, the entity finds that an unfavorable 224
audit report or any portion thereof is unsubstantiated, the 225
entity shall dismiss the audit report or such portion 226
without the necessity of any further proceedings. 227
[4.] 5. Each entity conducting an audit shall provide 228
a copy of the final audit report, after completion of any 229
appeal process, to the plan sponsor. Such report shall 230
include the total amount of recoupment returned to the plan 231
sponsor, if any. 232
SCS SBs 984 & 968 9
[5.] 6. This section shall not apply to any 233
investigative audit that involves probable fraud, willful 234
misrepresentation, or abuse. 235
[6.] 7. This section shall not apply to any audit 236
conducted as part of any inspection or investigation 237
conducted by any governmental entity or law enforcement 238
agency. 239
376.387. 1. For purposes of this section, the 1
following terms shall mean: 2
(1) ["Covered person", the same meaning as such term 3
is defined in section 376.1257] "Contracted pharmacy", a 4
pharmacy located in Missouri participating in the network of 5
a pharmacy benefits manager through a direct or indirect 6
contract; 7
(2) ["Health benefit plan", the same meaning as such 8
term is defined in section 376.1350; 9
(3)] "Health carrier" [or "carrier", the same meaning 10
as such term is defined in section 376.1350], an entity 11
subject to the insurance laws and regulations of this state 12
that contracts or offers to contract to provide, deliver, 13
arrange for, pay for, or reimburse any of the costs of 14
health care services, including a sickness and accident 15
insurance company, a health maintenance organization, a 16
nonprofit hospital and health service corporation, or any 17
other entity providing a plan of health insurance, health 18
benefits, or health services, except that such plan shall 19
not include any coverage pursuant to a liability insurance 20
policy, workers' compensation insurance policy, or medical 21
payments insurance issued as a supplement to a liability 22
policy; 23
(3) "Maximum allowable cost", the per-unit amount that 24
a pharmacy benefits manager reimburses a pharmacist for a 25
SCS SBs 984 & 968 10
prescription drug, excluding a dispensing or professional 26
fee; 27
(4) "Maximum allowable cost list" or "MAC list", a 28
listing of drug products that meet the standard described in 29
this section; 30
[(4)] (5) "Pharmacy", the same meaning as such term is 31
defined in chapter 338; 32
[(5)] (6) "Pharmacy benefits manager", [the same 33
meaning as such term is defined in section 376.388] an 34
entity that contracts with pharmacies on behalf of health 35
carriers or health benefit plans to provide prescription 36
drug and pharmacist services; 37
(7) "Pharmacy benefits manager affiliate", a pharmacy 38
or pharmacist that directly or indirectly, through one or 39
more intermediaries, owns or controls, is owned or 40
controlled by, or is under common ownership or control with 41
a pharmacy benefits manager. 42
2. [No pharmacy benefits manager shall include a 43
provision in a contract entered into or modified on or after 44
August 28, 2018, with a pharmacy or pharmacist that requires 45
a covered person to make a payment for a prescription drug 46
at the point of sale in an amount that exceeds the lesser of: 47
(1) The copayment amount as required under the health 48
benefit plan; or 49
(2) The amount an individual would pay for a 50
prescription if that individual paid with cash. 51
3. A pharmacy or pharmacist shall have the right to 52
provide to a covered person information regarding the amount 53
of the covered person's cost share for a prescription drug, 54
the covered person's cost of an alternative drug, and the 55
covered person's cost of the drug without adjudicating the 56
claim through the pharmacy benefits manager. Neither a 57
SCS SBs 984 & 968 11
pharmacy nor a pharmacist shall be proscribed by a pharmacy 58
benefits manager from discussing any such information or 59
from selling a more affordable alternative to the covered 60
person. 61
4. No pharmacy benefits manager shall, directly or 62
indirectly, charge or hold a pharmacist or pharmacy 63
responsible for any fee amount related to a claim that is 64
not known at the time of the claim's adjudication, unless 65
the amount is a result of improperly paid claims or charges 66
for administering a health benefit plan. 67
5. This section shall not apply with respect to claims 68
under Medicare Part D, or any other plan administered or 69
regulated solely under federal law, and to the extent this 70
section may be preempted under the Employee Retirement 71
Income Security Act of 1974 for self-funded employer- 72
sponsored health benefit plans. 73
6. A pharmacy benefits manager shall notify in writing 74
any health carrier with which it contracts if the pharmacy 75
benefits manager has a conflict of interest, any commonality 76
of ownership, or any other relationship, financial or 77
otherwise, between the pharmacy benefits manager and any 78
other health carrier with which the pharmacy benefits 79
manager contracts. 80
7. The department of commerce and insurance shall 81
enforce this section] Upon each contract execution or 82
renewal between a pharmacy benefits manager and a pharmacy 83
or between a pharmacy benefits manager and a pharmacy's 84
contracting representative or agent, such as a pharmacy 85
services administrative organization, a pharmacy benefits 86
manager shall, with respect to such contract or renewal: 87
SCS SBs 984 & 968 12
(1) Include in such contract or renewal the sources 88
utilized to determine maximum allowable cost and update such 89
pricing information at least every seven days; and 90
(2) Maintain a procedure to eliminate products from 91
the maximum allowable cost list of drugs subject to such 92
pricing or modify maximum allowable cost pricing at least 93
every seven days, if such drugs do not meet the standards 94
and requirements of this section, in order to remain 95
consistent with pricing changes in the marketplace. 96
3. A pharmacy benefits manager shall reimburse 97
pharmacies for drugs subject to maximum allowable cost 98
pricing that has been updated to reflect market pricing at 99
least every seven days as set forth under subdivision (1) of 100
subsection 2 of this section. 101
4. A pharmacy benefits manager shall not place a drug 102
on a maximum allowable cost list unless there are at least 103
two therapeutically equivalent multisource generic drugs, or 104
at least one generic drug available from at least one 105
manufacturer, generally available for purchase by network 106
pharmacies from national or regional wholesalers. 107
5. All contracts between a pharmacy benefits manager 108
and a contracted pharmacy or between a pharmacy benefits 109
manager and a pharmacy's contracting representative or 110
agent, such as a pharmacy services administrative 111
organization, shall include a process to internally appeal, 112
investigate, and resolve disputes regarding maximum 113
allowable cost pricing. The process shall include the 114
following: 115
(1) The right to appeal shall be limited to fourteen 116
calendar days following the reimbursement of the initial 117
claim; and 118
SCS SBs 984 & 968 13
(2) A requirement that the pharmacy benefits manager 119
shall respond to an appeal described in this subsection no 120
later than fourteen calendar days after the date the appeal 121
was received by such pharmacy benefits manager. 122
6. For appeals that are denied, the pharmacy benefits 123
manager shall provide the reason for the denial and identify 124
the national drug code of a drug product that may be 125
purchased by contracted pharmacies at a price at or below 126
the maximum allowable cost and, when applicable, may be 127
substituted lawfully. 128
7. If the appeal is successful, the pharmacy benefits 129
manager shall: 130
(1) Adjust the maximum allowable cost price that is 131
the subject of the appeal effective on the day after the 132
date the appeal is decided; 133
(2) Apply the adjusted maximum allowable cost price to 134
all similarly situated pharmacies as determined by the 135
pharmacy benefits manager; and 136
(3) Allow the pharmacy that succeeded in the appeal to 137
reverse and rebill the pharmacy benefits claim giving rise 138
to the appeal. 139
8. Appeals shall be upheld if: 140
(1) The pharmacy being reimbursed for the drug subject 141
to the maximum allowable cost pricing in question was not 142
reimbursed as required under subsection 3 of this section; or 143
(2) The drug subject to the maximum allowable cost 144
pricing in question does not meet the requirements set forth 145
under subsection 4 of this section. 146
9. A pharmacy benefits manager shall provide plan 147
sponsors with such plan sponsor's pharmacy claims data as 148
reasonably requested by a plan sponsor. 149
SCS SBs 984 & 968 14
10. The pharmacy benefits manager or plan sponsor 150
shall provide the plan sponsor and department of commerce 151
and insurance documentation of any benefit design that 152
encourages or requires enrollees to fill prescriptions at 153
affiliated pharmacies. 154
11. A pharmacy benefits manager shall exercise good 155
faith and fair dealing in the administration of pharmacy 156
benefits and shall ensure that any conflicts of interest 157
that may clinically or financially impact covered patients 158
or the health benefit plan sponsor in a negative manner are 159
disclosed. 160
12. All disclosures required under this section shall 161
be provided to the plan sponsor or its authorized agent in a 162
universal manner. 163
13. If a pharmacy benefits manager or health plan has 164
an affiliated pharmacy or a pharmacy under common ownership, 165
the pharmacy benefits manager shall disclose to the plan 166
sponsor and the department of commerce and insurance: 167
(1) The amount charged per dosage unit to the 168
affiliated pharmacy; and 169
(2) The median amount charged per dosage unit at non 170
affiliated, in-network pharmacies. 171
14. The department of commerce and insurance may audit 172
pharmacy benefits manager to ensure compliance with this 173
section. 174
376.394. 1. As used in this section, the following 1
terms shall mean: 2
(1) "Acquisition cost", the set of National Average 3
Drug Acquisition Costs, "NADAC", as calculated by the 4
Centers for Medicare and Medicaid Services and reflected in 5
the most recently released public file; 6
SCS SBs 984 & 968 15
(2) "Critical access care pharmacy", a Missouri- 7
domiciled pharmacy with a physical location in the state of 8
Missouri that employs less than five hundred employees 9
across common ownership which is: 10
(a) Located in a county or city with fewer than fifty 11
thousand residents; or 12
(b) In a county or city with fifty thousand or more 13
residents and in an area within Missouri that is designated 14
as a Primary Care or Mental Health Health Professional 15
Shortage Area (HPSA) or a Medically Underserved Area by the 16
Health Resources and Services Administration (HRSA), an 17
agency of the U.S. Department of Health and Human Services; 18
or 19
(c) Any essential pharmacy as defined in Section 1860D- 20
42 of the Social Security Act, 42 U.S.C. 1395-152; 21
(3) "Similarly situated", a critical access care 22
pharmacy: 23
(a) That is in any of the pharmacy benefits manager's 24
networks; 25
(b) That purchases the particular drug or medical 26
product or device to which the finding applies from the same 27
pharmaceutical wholesaler as the pharmacy that prevailed in 28
the appeal; and 29
(c) To which the pharmacy benefits manager also 30
applies the challenged rate of reimbursement or actual cost. 31
2. Notwithstanding any provision of law to the 32
contrary, a pharmacy benefits manager shall not reimburse a 33
critical access care pharmacy for a prescription drug or 34
device an amount that is less than the actual cost to that 35
pharmacy for the prescription drug or device. 36
(1) A pharmacy benefits manager shall establish a 37
process for a pharmacy to appeal a reimbursement for failing 38
SCS SBs 984 & 968 16
to pay at least the actual cost and dispensing fee to the 39
critical access care pharmacy for the prescription drug or 40
device and shall permit a critical access care pharmacy or 41
its designated agent to file an appeal using the standard 42
appeal form described in this section. 43
(2) If a critical access care pharmacy chooses to 44
contest a reimbursement for failing to pay at least the 45
actual cost the critical access care pharmacy incurred for a 46
particular drug or medical product or device, then the 47
critical access care pharmacy has the right to designate a 48
pharmacy services administrative organization or other agent 49
to file and handle its appeal. 50
(3) The department of commerce and insurance shall 51
create and make available to pharmacy benefits managers and 52
covered entities a standard form to be used by a critical 53
access care pharmacy or its designated agent to file an 54
appeal pursuant to this subsection with a pharmacy benefits 55
manager or covered entity. 56
3. If a critical access care pharmacy or agent acting 57
on behalf of a critical access care pharmacy prevails in an 58
appeal provided for in this section, then within seven 59
business days after notice of the appeal is received by the 60
pharmacy benefits manager or covered entity, the pharmacy 61
benefits manager or covered entity shall: 62
(1) Make the necessary change to the challenged rate 63
of reimbursement or actual cost; 64
(2) If the product involved in the appeal is a drug, 65
provide to the critical access care pharmacy or agent the 66
national drug code number for the drug on which the change 67
is based; 68
SCS SBs 984 & 968 17
(3) Permit the challenging critical access care 69
pharmacy to reverse and rebill the claim upon which the 70
appeal is based; 71
(4) Pay or waive the cost of any transaction fee 72
required to reverse and rebill the claim; 73
(5) Reimburse the critical access care pharmacy at 74
least in an amount equal to the critical access care 75
pharmacy's actual cost for the prescription drug or device; 76
and 77
(6) Apply the findings from the appeal as to the rate 78
of reimbursement and actual cost for the particular drug or 79
medical product or device to other similarly situated 80
critical access care pharmacies. 81
4. It is a violation of this section if, after an 82
appeal in which a pharmacy or agent acting on behalf of a 83
critical access care pharmacy prevails, a pharmacy benefits 84
manager or covered entity fails to reimburse the critical 85
access care pharmacy at least actual cost. 86
5. If a critical access care pharmacy or agent acting 87
on behalf of a critical access care pharmacy loses or is 88
denied an appeal provided for in this section, then: 89
(1) If the product associated with the national drug 90
code number or unique device identifier is available at a 91
cost that is less than the challenged rate of reimbursement 92
from a pharmaceutical wholesaler in this state, then within 93
seven business days after notice of the appeal is received 94
by the pharmacy benefits manager or covered entity, the 95
pharmacy benefits manager or covered entity shall provide 96
the appealing critical access care pharmacy or agent with: 97
(a) The name of the national or regional 98
pharmaceutical wholesalers operating in this state that have 99
the particular drug or medical product or device currently 100
SCS SBs 984 & 968 18
in stock at a price that is less than the amount of the 101
challenged rate of reimbursement; and 102
(b) If the product involved in the appeal is a drug, 103
then the national drug code number for the drug; or 104
(c) If the product involved is a medical device, then 105
the unique device identifier for the device; and 106
(2) If the product associated with the national drug 107
code number or unique device identifier is not available at 108
a cost that is less than the challenged rate of 109
reimbursement from the pharmaceutical wholesaler from whom 110
the critical access care pharmacy purchases the majority of 111
prescription pharmaceutical products for resale, then the 112
pharmacy benefits manager shall adjust the challenged rate 113
of reimbursement to an amount equal to or greater than the 114
appealing critical access care pharmacy's actual cost and 115
permit the critical access care pharmacy to reverse and 116
rebill each claim affected by the inability to procure the 117
pharmaceutical product at a cost that is equal to or less 118
than the previously challenged rate of reimbursement. The 119
pharmacy benefits manager shall pay or waive the cost of any 120
transaction fee required to reverse and rebill the claim. 121
6. The department of commerce and insurance shall 122
enforce this section. 123
376.399. 1. Health benefit plans beginning on or 1
after January 1, 2027 shall comply with H.R. 7148, the 2
Consolidated Appropriations Act, 2026. 3
2. For plan years beginning on or after January 1, 4
2027, no contract or arrangement or renewal or extension of 5
a contract or arrangement, entered into on or after January 6
1, 2027, for services between a covered plan and a covered 7
service provider, or between a sponsor of a covered plan and 8
a covered service provider, through a health insurance 9
SCS SBs 984 & 968 19
issuer offering group health insurance coverage, a third- 10
party administrator, an entity providing pharmacy benefit 11
management services, or other entity, for pharmacy benefit 12
management services, is reasonable within the meaning of 13
this section unless such entity providing pharmacy benefit 14
management services: 15
(1) Remits one hundred percent of rebates, fees, 16
alternative discounts, and other remuneration received from 17
any applicable entity that are related to utilization of 18
drugs or drug spending under such health plan or health 19
insurance coverage, to the group health plan or, in the case 20
of a health insurance issuer offering group health insurance 21
coverage in connection with a group health plan, to the 22
health insurance issuer offering group health insurance 23
coverage on behalf of the plan; and 24
(2) Does not enter into any contract for pharmacy 25
benefit management services on behalf of such a plan or 26
coverage, with an applicable entity unless one hundred 27
percent of rebates, fees, alternative discounts, and other 28
remuneration received under such contract that are related 29
to the utilization of drugs or drug spending under such 30
group health plan or health insurance coverage are remitted 31
to the group health plan or, in the case of a health 32
insurance issuer offering group health insurance coverage in 33
connection with a group health plan, to the health insurance 34
issuer on behalf of the plan by the entity providing 35
pharmacy benefit management services. 36
Nothing this subsection shall be construed to affect the 37
term of a contract or arrangement, as in effect on January 38
1, 2027, except that such subdivision shall apply to any 39
renewal or extension of such a contract or arrangement 40
SCS SBs 984 & 968 20
entered into on or after such effective date, as so 41
described. 42
3. With respect to such rebates, fees, alternative 43
discounts, and other remuneration, the rebates, fees, 44
alternative discounts, and other remuneration under this 45
section shall be remitted: 46
(1) On a quarterly basis, to the group health plan or, 47
in the case of a health insurance issuer offering group 48
health insurance coverage in connection with a group health 49
plan, to the group health insurance issuer on behalf of the 50
plan, not later than ninety days after the end of each 51
quarter; or 52
(2) In the case of an underpayment in a remittance for 53
a prior quarter, as soon as practicable, but not later than 54
ninety days after notice of the underpayment is first given; 55
(3) Fully disclosed and enumerated to the group health 56
plan or health insurance issuer; and 57
(4) Returned to the covered service provider for 58
pharmacy benefit management services on behalf of the group 59
health plan if any audit by a plan sponsor, issuer or a 60
third party designated by a plan sponsor, indicates that the 61
amounts received are in excess of correct amounts after such 62
amounts have been paid to the group health plan, in the 63
amount of such excess. 64
4. The department of commerce and insurance shall 65
enforce this section and shall have the right to any 66
information in the section from any pharmacy benefits 67
manager under investigation individually or in aggregate per 68
their request. 69
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