This bill amends the Code of West Virginia to regulate pharmacy benefit managers (PBMs) by establishing specific reimbursement requirements 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, unless certain conditions are met. These conditions include scenarios where the pharmacy submits charges below 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 considered full payment.

The bill also includes provisions to prevent discrimination against 340B entities by PBMs, ensuring they are reimbursed fairly and not subjected to additional burdens compared to non-340B pharmacies. 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 unfairly affect pharmacy reimbursements based on patient outcomes or impose additional fees. 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