Pharmacy benefits managers are the intermediary between health insurance plans and their network pharmacies which process claims and determine the amount pharmacies are reimbursed for dispensing covered prescriptions. They deal directly with drug manufacturers by negotiating discounts or rebates on drug prices. Pharmacy benefits managers may also be affiliated with particular pharmacies that also participate in the network. Under existing law, they are licensed and regulated by the Department of Insurance. This bill would expand oversight by the Department of Insurance by setting benchmarks for the amounts that pharmacy benefits managers reimburse pharmacies, and by regulating how they process claims, determine payment amounts, and use manufacturer rebates. This bill would prohibit pharmacy benefits managers from requiring or influencing health insurance beneficiaries to purchase a particular variant of a prescription drug or only use certain pharmacies within a health plan network. This bill would authorize a health insurance plan, a plan beneficiary, or a pharmacy to bring a cause of action against a pharmacy benefits manager for damages due to a violation of this act. This bill would also further regulate the audit of a pharmacy by a pharmacy benefits manager under The Pharmacy Audit Integrity Act by specifying the circumstances under which a pharmacy benefits manager may recoup funds from a pharmacy that was overpaid for claims.

Statutes affected:
Introduced: 27-45A-1, 27-54A-3, 27-45A-5, 27-45A-6, 27-45A-7, 27-45A-8, 27-45A-9, 27-45A-10