The proposed bill, if enacted, would amend current statutes by adding a new section (20-3335) that establishes specific requirements for pharmacy benefit managers (PBMs) regarding reimbursement practices. Under the new law, PBMs would be prohibited from reimbursing pharmacists or pharmacies for prescription drugs or devices at amounts lower than the actual costs incurred by those entities. Additionally, PBMs would be required to pay a professional dispensing fee that aligns with the fee-for-service methodology used in the state plan for medical assistance, as approved by the Centers for Medicare and Medicaid Services (CMS). The bill also outlines the appeal process for pharmacists or pharmacies who believe their reimbursement rates do not comply with these new requirements.

Furthermore, the bill mandates that PBMs include procedures for appeals in their contracts with pharmacists or pharmacies, requiring appeals to be filed within seven business days of reimbursement. If a pharmacist or pharmacy prevails in an appeal, the PBM must make necessary adjustments to the reimbursement within seven business days. The bill also defines terms such as "similarly situated pharmacists or pharmacies" and "state plan," and clarifies that these provisions will apply to contracts entered into, amended, extended, or renewed after December 31, 2025.

Statutes affected:
Introduced Version: 20-3335