This bill amends the Code of West Virginia to regulate pharmacy benefit managers (PBMs) more stringently, particularly regarding reimbursement practices for pharmacies and pharmacists. It introduces a provision that prohibits PBMs from reimbursing for prescription drugs or pharmacy services at amounts lower than the national average drug acquisition cost, plus a professional dispensing fee of $10.49. However, starting January 1, 2026, this requirement will not apply if the pharmacy's submitted charges are lower than the mandated amounts or if the cost-sharing amount paid by the insured is less than what their health plan imposes. Additionally, the bill clarifies that an insured's payment at the point of sale cannot exceed the lesser of their defined cost share or the cash price for the prescription, with cash payments being considered full payment.

The bill also includes provisions to prevent discrimination against 340B entities by PBMs, ensuring that they are reimbursed fairly and not subjected to additional burdens that could lead to higher administrative costs. It mandates that any reimbursement methodologies used by PBMs must be filed with the commissioner and comply with the new reimbursement standards. Furthermore, it prohibits PBMs from engaging in practices that could unfairly affect pharmacies based on their participation in the 340B program or from imposing fees that could disadvantage them. Overall, the bill aims to enhance transparency and fairness in the pharmacy reimbursement process while protecting the rights of pharmacies and patients.

Statutes affected:
Introduced Version: 33-51-9