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 lower charges or the cost-sharing amount paid by the insured is less than what their health plan imposes. Additionally, the bill clarifies that an insured's cost-sharing 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 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, such as imposing fees based on patient outcomes or excluding pharmacies from their networks based on their participation in the 340B program. Overall, the bill aims to enhance transparency and fairness in the reimbursement process for pharmacies and protect consumers' rights at the point of sale.

Statutes affected:
Introduced Version: 33-51-9