The proposed bill amends Chapter 3, Title 41 of the Idaho Code to establish new regulations for pharmacy benefit managers (PBMs) and third-party payers concerning dispensing fees. A new section, 41-349A, is introduced to guarantee that independent pharmacies receive reimbursement that is at least equal to the national average drug acquisition cost (NADAC) plus a minimum professional dispensing fee of $12.35, which will be adjusted annually for inflation. The Idaho Department of Insurance will provide guidance to ensure compliance with these reimbursement rates. Additionally, existing Section 41-349 is amended to define key terms and revise provisions related to dispensing fees, including prohibiting PBMs from charging pharmacies different amounts for prescription drugs than what they reimburse and mandating that reimbursements occur without processing fees.

The bill further establishes a process for pharmacies to appeal reimbursement rates for generic drugs within thirty days of payment and requires PBMs to provide access to a maximum allowable cost list for each pharmacy. It prohibits PBMs from reducing payments for pharmacy services through reconciliation processes and restricts retroactive claim denials unless specific conditions are met. Contractual requirements for PBMs are also outlined, including the use of a pass-through pricing model, the prohibition of spread pricing, and the obligation to pass 100% of manufacturer rebates to health plans. The legislation aims to enhance transparency and fairness in pharmacy benefit management, ensuring that pharmacies are adequately compensated and protected from unfair practices. The act is set to take effect immediately upon passage and approval.

Statutes affected:
Bill Text: 41-349