The bill, 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 key provisions. It mandates that health benefit plans providing pharmacy benefits must include a unique identifier on the front of each enrollee's identification card, allowing pharmacists to determine the regulatory status of the plan. Additionally, the bill outlines specific limitations on claim payment adjustments, stating that a health benefit plan issuer or pharmacy benefit manager cannot deny or reduce a claim payment after adjudication unless certain conditions, such as fraud or substantive errors, are met.

Furthermore, the bill introduces new sections that require health benefit plan issuers or pharmacy benefit managers to provide online access to pharmacy benefit network contracts, ensuring pharmacists can review all terms and modifications. It prohibits the imposition of fees before providing full contract details and prevents any penalties for pharmacists who choose not to participate in a pharmacy benefit network. The bill also repeals certain existing provisions and specifies that the new regulations will apply to health benefit plans and contracts issued or renewed after January 1, 2026. The act is set to take effect on September 1, 2025.

Statutes affected:
Introduced: Insurance Code 1369.153, Insurance Code 1369.252, Insurance Code 1369.259, Insurance Code 1369.605 (Insurance Code 1369)