S.B. No. 1236 aims to enhance the relationship between pharmacists or pharmacies and health benefit plan issuers or pharmacy benefit managers by introducing several amendments to the Insurance Code. Notably, it establishes that a group number on an identification card for enrollees in applicable health benefit plans can only be assigned to those enrollees. The bill also modifies the heading of Section 1369.259 to emphasize limitations on payment adjustments and prohibits the use of extrapolation in recoupment processes. Additionally, it introduces new provisions that restrict health benefit plan issuers or pharmacy benefit managers from denying or reducing claim payments after adjudication, except under specific circumstances such as fraud or clerical errors.

Furthermore, the bill mandates that health benefit plan issuers or pharmacy benefit managers provide online access to pharmacy benefit network contracts, ensuring transparency and accessibility for pharmacists and pharmacies. It outlines the conditions under which adverse material changes to contracts can occur, requiring mutual agreement between parties and proper notification. The legislation also prohibits certain participation requirements and fees before providing full contract details to pharmacists or pharmacies. The changes will take effect on September 1, 2025, and will apply to contracts entered into or renewed after this date.

Statutes affected:
Introduced: Insurance Code 1369.153, Insurance Code 1369.252, Insurance Code 1369.259, Insurance Code 1369.605 (Insurance Code 1369)
Senate Committee Report: Insurance Code 1369.153, Insurance Code 1369.259, Insurance Code 1369.605 (Insurance Code 1369)
Engrossed: Insurance Code 1369.153, Insurance Code 1369.259, Insurance Code 1369.605 (Insurance Code 1369)
House Committee Report: Insurance Code 1369.153, Insurance Code 1369.259, Insurance Code 1369.605 (Insurance Code 1369)
Enrolled: Insurance Code 1369.153, Insurance Code 1369.259, Insurance Code 1369.605 (Insurance Code 1369)