AT A GLANCE

This bill permits network-plan pharmacists and pharmacies, beginning January 1, 2026, to decline items or services when reimbursement falls below acquisition cost and requires administrative organizations to provide contracts within three calendar days.

The bill adds General Obligations Law § 5-338, making it unlawful for a person or entity to directly or indirectly own, operate, control, or direct any part of an insurance company, pharmacy benefit manager, or pharmacy, or any combination of those entities. “Indirect control” includes agreements, arrangements, contracts, ownership interests, or other relationships that enable a pharmacy owner or operator to influence or direct an insurance company’s or pharmacy benefit manager’s operations in New York.

A person or entity violating the prohibition must divest from the relevant pharmacy, insurance company, and/or pharmacy benefit manager no later than three years after the section’s effective date. The Attorney General may bring a civil action and seek a $10,000-per-day civil penalty, costs, and reasonable attorneys’ fees.

An insurance company, pharmacy, or pharmacy benefit manager found by the Attorney General to be in violation becomes ineligible to receive payments under any program authorized by Article 5 of the Social Services Law until the Attorney General determines that the violation has been resolved. The act takes effect immediately.

AT A GLANCE

This bill, beginning on the first day of the seventh month after enactment, limits PBM compensation, prohibits spread pricing and steering, and requires pass-through pricing and disclosures for PBMs, carriers, and state health programs.

AT A GLANCE

This bill prohibits PBMs from using spread pricing and limits their compensation to itemized fees for bona fide services in contracts entered into, renewed, modified, or amended after the seventh month begins.

The bill adds section 5-338 to New York’s General Obligations Law to prohibit any person or entity from directly or indirectly owning, operating, controlling, or directing any part of an insurance company, pharmacy benefit manager, or pharmacy, including combinations of those entities. “Indirect control” includes agreements, arrangements, contracts, ownership interests, or other relationships that enable a pharmacy owner or operator to influence or direct an insurance company or pharmacy benefit manager.

Entities violating the prohibition must divest from the relevant pharmacy, insurance company, and/or pharmacy benefit manager within three years after the section’s effective date. The attorney general may bring a civil action and recover a civil penalty of $10,000 per day for each violation, plus costs and reasonable attorneys’ fees.

An insurance company, pharmacy, or pharmacy benefit manager found by the attorney general to be in violation becomes ineligible to receive payments under any program authorized by article five of the Social Services Law until the attorney general deems the violation resolved. The act takes effect immediately.

AT A GLANCE

This bill requires pharmacy benefit managers to comply with strengthened audit, reimbursement-appeal, prior-authorization, reporting, and contracting requirements and prohibits specified practices for covered contracts affected six months after enactment.

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This bill requires courts to vacate arrests, convictions, or adjudications for human-trafficking, intimate-partner-violence, and sexual-violence victims who prove victimization directly caused the offense and lacked requisite intent, except murder.

AT A GLANCE

This bill requires pharmacy benefit managers to reimburse community pharmacies at least Massachusetts Medicaid rates and prohibits retroactive discounts, steering, and unequal treatment of non-affiliated pharmacies.

AT A GLANCE

This bill requires the Office of Health Resource Planning to assess pharmacy services in Massachusetts, identify pharmacy deserts and their effects, and submit findings to specified agencies and committees by September 1, 2026.

AT A GLANCE

This bill establishes a parental right to home-educate children, generally without declarations or assessments, and requires pharmacy benefit managers to secure carrier agreements and annually report rebate data.

AT A GLANCE

This bill establishes statewide and individual health care entity primary care expenditure targets of 10% in 2027, 12.5% in 2028, and 15% in 2029.

Health plans providing prescription drug benefits must give covered persons at least 60 days’ notice before implementing formulary deletions, replacing the prior 45-day period. The required notice must use an easily legible font of at least 14-point size, replacing the prior 12-point minimum. Any denial of a request through the prescription-drug exception process is designated an adverse determination.

Plans must maintain and provide to the commissioner upon request documentation of formulary changes, including the change date and reason; the complete maximum allowable cost list for each pharmacy subject to such a list; and documentation of maximum allowable cost-list changes, including the change date and when affected pharmacies were notified. The changes take effect January 1, 2027.

The bill establishes Section 3902.78 of the Ohio Revised Code to prohibit a health plan issuer—including a pharmacy benefit manager or other third-party administrator—from prohibiting, restricting, or penalizing a pharmacy, pharmacist, or personally furnishing prescriber for offering, directly or through a third party, services or products that increase prescription-drug transparency or patient access in connection with a health benefit plan.

Protected activities include simplified or electronic payment processes and payment plans; adherence-support services or communications; information on patients’ out-of-pocket drug costs or alternative medications; electronic transactions providing prescription-drug cost and benefit information; electronic prior-authorization support; sharing patient claims or other health-care transaction data with the patient, the patient’s provider and business associates, or a patient-authorized third party; and, as permitted by state and federal law, prescription-drug copayment assistance or other out-of-pocket cost support.

The bill requires the Department of Managed Health Care to maintain a public website listing, for each licensed pharmacy benefit manager, its legal name, license number and status, initial licensure date, and license expiration date. The department must implement the requirement using existing resources; if it determines that additional resources are necessary, the requirement becomes operative only after sufficient funding is appropriated through the annual Budget Act or another funding measure.

AT A GLANCE

Beginning July 1, 2027, this bill requires persons providing pharmacy benefit management services to Ohio-domiciled plans or sponsors to obtain a license from the superintendent of insurance.

AT A GLANCE

This bill requires PEIA to solicit competitive bids for a separate pharmacy cost-containment vendor by July 1, 2026, and establishes a Medicaid pilot and limits PBM pricing and rebates.

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This act prohibits pharmacy benefit managers from operating, offering to operate, or holding themselves out as PBMs in Rhode Island without an Office of the Health Insurance Commissioner certificate beginning January 1, 2027.

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This bill requires pharmacy benefit managers to disclose specified financial, contractual, and utilization information to insurers beginning August 1, 2027, and prohibits unauthorized prescription substitutions and certain pharmacy-contract restrictions.

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This bill requires pharmacy benefit managers operating in Rhode Island to obtain a certificate of authority from the health insurance commissioner, allowing provisional certification for two years after application guidance.

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This bill requires pharmacy benefit managers, beginning August 1, 2027, to disclose specified financial, utilization, contract, and conflict-of-interest information to insurers.

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This bill requires specified health plans, for contracts entered into, renewed, or amended on or after July 1, 2028, to implement an all-payer primary care capitation model.

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This bill requires specified public and commercial health-insurance arrangements to implement a standardized all-payer primary-care capitation model for contracts entered into, renewed, or amended on or after July 1, 2028.

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This bill requires pharmacy benefits managers operating in Massachusetts to obtain licenses from the commissioner of insurance and follow pricing, reimbursement, disclosure, and provider-appeal requirements, including responses within 10 business days.

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This bill requires pharmacy benefit managers to act with care, good faith, prudence, fairness, transparency, and professionalism toward enrollees, health plans, and providers, prioritizing enrollees when duties conflict.

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This bill requires pharmacy benefit managers to perform services with care, fairness, transparency, and professionalism in the best interests of enrollees, health plans, and providers, prioritizing enrollees when duties conflict.

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This bill requires pharmacy benefit managers serving MassHealth or the Group Insurance Commission to restrict MAC lists to qualifying, available, nonobsolete drugs, update them within seven calendar days of specified changes, and maintain pharmacy appeals.

AT A GLANCE

This bill requires pharmacy benefits managers and covered entities to list only qualifying drugs, update maximum allowable costs every three business days, reimburse pharmacies at acquisition cost or more, and resolve appeals within seven business days.

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This bill prohibits pharmacy benefit managers from receiving compensation from Massachusetts carriers or health plans except through contractually specified fees, bans spread pricing, and requires annual compliance certifications.

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Beginning March 1, 2027, this act requires pharmacy benefit managers to submit annual transparency reports to the Department as a condition of licensure, available publicly on request.

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This bill prohibits pharmacy benefit managers from acquiring or holding Arizona retail-pharmacy permits and requires the Board of Pharmacy to revoke or refuse renewal of violating permits after December 31, 2026.

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This bill requires pharmacy benefit managers serving non-Office of Group Benefits health plans, beginning January 1, 2026, to reimburse pharmacies using NADAC or WAC and provide a nonrecoverable Medicaid-level dispensing fee.

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This act requires pharmacy benefit managers to act solely for health plans and enrollees, prohibits spread pricing and rebate retention, and mandates disclosed compensation and quarterly pass-throughs, subject to federal law.

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This act requires PBMs, for policies or contracts issued, renewed, modified, altered, or amended on or after January 1, 2027, to pay participating pharmacies at least NADAC or pharmacy acquisition cost when unavailable, plus sufficient dispensing fees.

AT A GLANCE

This bill requires pharmacy benefit managers to pay participating pharmacies at least the applicable NADAC rate, or acquisition cost when unavailable, plus dispensing fees under policies or contracts modified on or after January 1, 2027.

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This bill prohibits pharmacy benefits managers, beginning January 1, 2027, from directly or indirectly acquiring, holding, or exercising ownership, beneficial interests, or operational control over Tennessee-licensed pharmacies.

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This bill prohibits pharmacy benefits managers, beginning January 1, 2027, from directly or indirectly owning, controlling, or beneficially owning Tennessee pharmacy licenses or license holders, regardless of ownership percentage.

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This bill establishes uniform standards for audits of pharmacists and pharmacies, requiring preliminary reports within 120 days and final reports within six months after preliminary reports or final appeals, whichever is later, while limiting recoupment.

AT A GLANCE

This bill limits carriers to one pharmacy audit per 12 months, while permitting issue-specific exception audits when documented evidence indicates fraud, abuse, misrepresentation, or criminal wrongdoing.

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This bill prohibits Rhode Island pharmacy benefits managers from engaging in unfair trade practices, including spread pricing, pharmacy steering, improper refill restrictions, prescription-information misuse, and unlicensed operation.

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This bill prohibits persons from owning both a health plan issuer or pharmacy benefit manager and a health care provider or management services organization, unless services target people outside Ohio.

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This bill prohibits pharmacy benefit managers from requiring covered persons to pay more than the lesser of their plan’s copayment or prescription cash price for contracts entered or modified on or after August 28, 2018.

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This bill requires PBMs under new or renewed arrangements for health plans beginning January 1, 2027, to remit 100% of drug-related remuneration quarterly within 90 days.

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This bill requires pharmacy benefit managers, beginning January 1, 2026, to reimburse contracted pharmacists and local pharmacies at least NADAC plus Louisiana’s Medicaid dispensing fee, or wholesale acquisition cost when unavailable.

AT A GLANCE

This bill subjects expanded categories of pharmacy benefit managers, including insurers, to written-agreement, fiduciary, reporting, auditing, and consumer-protection requirements beginning January 1, 2027.

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This bill requires PBMs to provide plan sponsors and the Department of Banking and Insurance plain-language, machine-readable drug-spending reports at least every six months for contracts entered into on or after the first day of the 12th month following enactment.

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This bill prohibits pharmacy benefits managers and affiliates from receiving commissions or non-bona fide service fees for administering prescription benefits, requiring flat-dollar, fair-market-value fees for itemized services.

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This bill requires PBMs and applicable entities to include disclosure requirements in contracts entered after the first day of the 12th month following enactment and requires PBMs to submit drug-spending reports to plan sponsors every six months.

The bill requires a health benefits plan covering prescription drugs or pharmacy services and administered or managed by a pharmacy benefits manager (PBM) to allow any pharmacy that meets the plan’s standard contract terms and conditions to participate as a network pharmacy. Contract terms and conditions must be reasonable and relevant, as determined by the Commissioner of Banking and Insurance. In making that determination, the commissioner must review existing network-pharmacy contract terms and the reimbursement and dispensing fees paid by health benefits plans, including whether those payments cover ingredient and operational costs.

The commissioner may adopt rules under the Administrative Procedure Act to implement these requirements. The bill takes effect on the first day of the 13th month following enactment and applies to health-benefits-plan/PBM contracts initiated or renewed on or after the enactment date.

AT A GLANCE

This bill prohibits pharmacy benefits managers from using spread pricing in new, extended, or renewed arrangements and requires them to remit 100 percent of related rebates, fees, and discounts to plan purchasers.

AT A GLANCE

This bill prohibits PBMs from using spread pricing or entering new, extended, or renewed contracts using that model, and requires them to remit 100% of related remuneration to carriers, plans, or purchasers.

AT A GLANCE

This bill requires pharmacy-benefit managers, for plan years beginning on or after January 1, 2027, to remit 100% of drug-related rebates, fees, discounts, and other remuneration quarterly to group health plans or insurers.

AT A GLANCE

This bill prohibits pharmacy benefits managers from directly or indirectly acquiring or holding an interest in, or permit to operate, a pharmacy practice site beginning July 1, 2027, subject to special permits.

The bill amends Section 9 of P.L.2023, c.107 to prohibit a pharmacy benefits manager or its affiliate from receiving compensation for administering or managing prescription drug benefits through a commission structure or any fee other than a bona fide service fee. A bona fide service fee must reflect fair market value as determined by the Commissioner of Banking and Insurance, cover an itemized service actually performed for the purchaser that the purchaser otherwise would perform or contract for, and not be passed on in whole or in part to a covered person.

The fee must be a flat-dollar amount and may not be directly or indirectly based on drug or benchmark prices; discounts, rebates, fees, or other remuneration associated with drugs dispensed to covered persons; formulary placement decisions; the volume or value of referrals or business between the pharmacy benefits manager and purchaser; or other amounts or methodologies prohibited by the department. The requirements take effect on the first day of the fourth month after enactment and apply to contracts and agreements entered into, renewed, modified, or amended on or after that date.

The bill requires a health benefits plan covering prescription drugs or pharmacy services and administered or managed by a pharmacy benefits manager to allow any pharmacy meeting the plan’s standard contract terms and conditions to participate as a network pharmacy. Contract terms and conditions must be reasonable and relevant, as determined by the Commissioner of Banking and Insurance. In making that determination, the commissioner must review current network-pharmacy contract terms and whether reimbursement and dispensing fees are sufficient to cover ingredient and operational costs.

The commissioner may adopt rules under the Administrative Procedure Act to implement the requirements. The act takes effect on the first day of the 13th month following enactment and applies to contracts between health benefits plans and pharmacy benefits managers initiated or renewed on or after the enactment date.

Section 6808 of New York’s Education Law would gain a new subdivision requiring chain and community pharmacies to obtain an official designation. A “chain pharmacy” is defined as a publicly traded company with at least 20 licensed New York pharmacies under the same ownership; a “community pharmacy” is a privately held company with fewer than 20 such pharmacies under the same ownership.

Government-owned, hospital-owned, supermarket or general-merchandise-store-owned pharmacies, pharmacies operated as extensions of specified medical or outpatient facilities, pharmacies owned by corporate chains with stores outside New York, mail-order pharmacies, and pharmacies owned by pharmacy benefit managers or health insurers are excluded from the community-pharmacy category. Each qualifying chain or community pharmacy must apply for its designation using a Department of Education form, renew the designation every three years, and pay a $500 application fee.

The act would take effect 90 days after becoming law. Rules or regulations needed to implement it may be adopted, amended, or repealed immediately and completed by the effective date.

AT A GLANCE

This bill requires payors to remit providers’ clean claims in full within 30 calendar days of receipt, with claim-level accounting, for claims paid on or after November 1, 2026, and prohibits shifting funding risks to providers.

AT A GLANCE

This bill requires pharmacy benefit managers contracting with Oklahoma’s self-insured Employees Insurance Plan to recognize plan-data ownership, ensure pharmacy access, disclose pricing, and obtain written approval for formulary changes.

Pharmacy benefits managers (PBMs) must pay an administrative fee when they increase reimbursement for a drug, medical product, or device following a reimbursement appeal—including an adjustment required because a denied appeal lacked evidence of below-cost availability—and then reduce reimbursement for the same item or National Drug Code within 30 calendar days after the appeal determination. The fee must be at least $100 per occurrence; if unpaid after 90 days, it increases to at least $500, and if unpaid after 180 days, to at least $1,000.

An appeal increase that remains below the pharmacy’s acquisition cost is treated as a denial. Such denials must meet the requirements for denial explanations and documentation, and trigger the administrative-fee provisions. The bill also updates related terminology from “pharmacy benefits manager” to “PBM” and makes conforming changes to reimbursement-appeal provisions, including applying the denial and fee rules to the existing covered reimbursement methodologies and renumbering the subsequent prohibition on collecting additional amounts from patients or plan sponsors.

The act takes effect November 1, 2026.

AT A GLANCE

This bill requires pharmacy benefit managers and insurers to disclose affiliates, report claims-level financial data quarterly, and pass through rebates while prohibiting disguised spread pricing and imposing $1 million penalties.

AT A GLANCE

This bill requires pharmacy benefit managers engaging in prescription steering, and health-plan operators whose contracted managers do so, to pay the Division a 10-percent surcharge on prior-year Massachusetts pharmacy reimbursements.

AT A GLANCE

This bill requires contracts between pharmacy benefit managers and community pharmacies to guarantee Medicaid-based reimbursement and dispensing fees, prohibit retroactive discounts and steering, and ensure transparent, timely maximum-allowable-cost pricing and appeals.

The document outlines amendments to Section 38-71-2240 of the South Carolina Code of Laws, focusing on the pharmacy benefits management industry. The amendments mandate that pharmacy benefits managers provide unobstructed access to their Maximum Allowable Cost Lists for patients, consumers, and network pharmacy providers.

Key provisions include a requirement for pharmacy benefits managers to update their Maximum Allowable Cost Lists at least once every seven calendar days. Additionally, a process will be established for network pharmacy providers and pharmacies to access these updates.

The amendments also introduce a reasonable internal appeal procedure for pharmacies to contest reimbursement rates that fall below their acquisition costs for drugs. Furthermore, there will be an external review process for denied internal appeals conducted by an independent review organization.

These changes are expected to enhance transparency within the pharmacy benefits management system and may influence reimbursement rates for pharmacies. The act will take effect upon approval by the Governor.

The document outlines amendments to the South Carolina Code of Laws that affect pharmacies and pharmacy benefits managers (PBMs). One significant change requires all pharmacies in South Carolina to cooperate with federal and state acquisition cost surveys, specifically the National Average Drug Acquisition Cost (NADAC) survey.

Additionally, the amendments establish new reimbursement guidelines for PBMs. They are required to reimburse pharmacies and pharmacists for prescription drugs and pharmacy services at or above the NADAC at the time of dispensing, along with a professional dispensing fee that must meet or exceed the current South Carolina Medicaid professional dispensing fee. In cases where NADAC is unavailable, the minimum reimbursement must be based on the Wholesale Acquisition Cost (WAC) plus the same professional dispensing fee.

Furthermore, a formal complaint process is introduced for pharmacies or pharmacists who believe they have been reimbursed below the mandated minimum. They can file a complaint with the Department of Insurance, which is obligated to review and make a determination within thirty days. If the complaint is upheld, the PBM must compensate the pharmacy or pharmacist for the underpayment and adjust reimbursements for similarly situated pharmacies.

Overall, this legislation aims to enhance financial accountability for PBMs and establish stricter reimbursement standards within the pharmacy industry.

AT A GLANCE

This act prohibits pharmacy benefits managers from restricting covered persons’ access to specialty medications through qualified, network-participating medically integrated pharmacies affiliated with treating specialty providers when those providers actively manage treatment.

AT A GLANCE

This bill prohibits pharmacy benefit managers, beginning November 1, 2026, from reimbursing pharmacies below acquisition cost plus Oklahoma’s minimum Medicaid dispensing fee and requires retroactive adjustments when appeals establish underpayment.

The bill amends Tennessee’s sales tax provisions to revise the treatment of prescription drugs and patent medicines. It replaces the existing exclusion in Tennessee Code Annotated § 67-4-708(2)(D) with an exclusion for prescription drugs and patent medicines that are not otherwise exempt under § 67-4-712(g)(1).

The bill adds an exemption from the tax for receipts from prescription drugs or medicines whose cost for a 30-day equivalent supply exceeds the Medicare Part D specialty-tier cost threshold applicable to 2025 plan years, as determined by the federal Centers for Medicare and Medicaid Services under 42 C.F.R. § 423.104(d)(2)(iv)(A). The exemption also covers services necessary for the proper preparation, storage, handling, administration, patient education, or post-sale monitoring of drugs or medicines qualifying for the exemption. The changes take effect July 1, 2025.

AT A GLANCE

This bill prevents Nebraska from imposing retaliatory requirements solely because it regulates Nebraska-licensed producers, while permitting equivalent burdens on producers from states imposing greater requirements.

The act authorizes the Alabama Commissioner of Insurance to employ two exempt-service employees to operate the Pharmacy Benefits Manager Division within the Department of Insurance. These positions are not subject to the state Merit System, are in addition to other exempt positions authorized for the department, and have compensation set by the commissioner. The act becomes effective June 1, 2026.

AT A GLANCE

This act prohibits pharmacy benefits managers from specified deceptive practices, including spread pricing, pharmacy steering, prescription-information exploitation, and operating in Rhode Island without required registration and licensure.

AT A GLANCE

This bill subjects all Rhode Island carrier and intermediary pharmacy audits to statutory standards, requires pharmacists to conduct or consult on clinical audits, and narrows investigative exceptions and audit frequency.

AT A GLANCE

This act requires carriers and PBMs to use pass-through pricing, prohibits spread pricing and discriminatory 340B practices, and bars retaliation against pharmacies beginning July 1, 2027.

The law requires a pharmacy benefits manager to allow a covered person using a mail-order pharmacy to obtain the prescription from a network pharmacy when access is disrupted. If delivery is delayed by more than one day beyond the mail-order pharmacy’s expected delivery date, the network pharmacy must provide up to a seven-day supply or the smallest prepackaged unit of the drug. If the drug arrives unusable, the network pharmacy must dispense the prescription as prescribed.

For either circumstance, the covered person may not be charged more than one copayment, coinsurance payment, or other out-of-pocket payment for dispensing the drug.

AT A GLANCE

This bill requires PBMs and managed care organizations to reimburse community pharmacies at least NADAC, or WAC when unavailable, plus the statutory dispensing fee, and prohibits below-standard reductions through fees or adjustments.

AT A GLANCE

This bill requires pharmacy benefit managers and auditing entities to meet statewide audit, reporting, reimbursement, rebate, and patient-protection standards, including limits on fees, recoupments, and cost sharing.

AT A GLANCE

This bill requires PBMs and managed care organizations to reimburse community pharmacies at least NADAC, or WAC if unavailable, plus the statutory dispensing fee, and prohibits below-cost reductions.

AT A GLANCE

This bill requires PBMs and managed care plans to use pass-through pricing for covered claims under contracts executed, amended, adjusted, or renewed on or after July 1, 2026, and prohibits spread pricing and steering.

AT A GLANCE

This bill requires pharmacy-benefit managers to register, report rebate and pricing information, follow pharmacy reimbursement limits, and requires audit entities to comply with pharmacy-audit safeguards.

The bill enacts R.S. 22:1867.1, effective January 1, 2027, to establish Medicare-price requirements for drugs used by the Office of Group Benefits and other state-sponsored insurance plans. Pharmaceutical manufacturers may not offer a drug for use by those plans at a price higher than Medicare pays for the same drug. Insurers, pharmacy benefit managers, and persons acting on their behalf may not reimburse, for those plans, any brand-name drug, biosimilar, or generic drug at a price below Medicare’s price for the same drug. The commissioner is responsible for enforcement and may adopt rules necessary to implement the provision.

AT A GLANCE

This bill requires the insurance commissioner to impose a $25,000 penalty per pharmacy-benefit violation without an aggregate cap and suspend or revoke the responsible license after 30 days.

The commissioner of commerce and insurance must use existing resources to publish, by October 1, 2026, a report on alleged violations of Tennessee Code Annotated § 56-7-3124 reported as occurring during the fiscal year ending June 30, 2026. The report must state the total number of reported violations, the commissioner’s investigation findings, and penalties imposed on pharmacy benefits managers found to have violated the provision.

A copy must be submitted to the chief clerks of the Senate and House of Representatives and to the legislative librarian; electronic publication and delivery are authorized. The act takes effect upon becoming law.

AT A GLANCE

This bill requires Louisiana pharmacy benefit managers to reimburse licensed pharmacies and pharmacists unaffiliated with them, retroactive to January 1, 2026, at least NADAC or, when unavailable, wholesale acquisition cost plus Louisiana’s inflation-adjusted dispensing fee.

AT A GLANCE

This bill prohibits PBMs from reimbursing pharmacies below NADAC plus the Medicaid dispensing fee, or WAC when unavailable, and requires full retroactive payment when appeals remain unreprocessed after 30 days.

AT A GLANCE

Beginning July 1, 2027, this bill requires carriers and PBMs to use pass-through pricing and direct all manufacturer rebates to plans or covered individuals while prohibiting spread pricing and specified pharmacy practices.

AT A GLANCE

This bill requires pharmacy benefit managers using maximum allowable cost reimbursement to update pricing lists at least every seven days and provide pharmacies a 14-business-day appeal process.

The bill adds a requirement to Illinois Insurance Code Section 513b1 that a pharmacy benefit manager may not reimburse a pharmacy or pharmacist for a prescription drug or pharmacy service below the national average drug acquisition cost applicable when the drug is administered or dispensed, plus a $10.49 professional dispensing fee. If that acquisition-cost figure is unavailable at that time, reimbursement may not be below the drug’s wholesale acquisition cost, as defined in federal law, plus the same $10.49 dispensing fee.

AT A GLANCE

Beginning July 1, 2026, this bill transfers regulation and licensing of pharmacy benefit managers and pharmacy services administrative organizations from the State Board of Pharmacy to the Commissioner of Insurance.

AT A GLANCE

This bill requires pharmacy benefit managers to reimburse non-affiliated pharmacies and pharmacists at least the net effective rate paid to affiliated providers for the same drug or service.

AT A GLANCE

This bill requires pharmacy benefit managers to allow pharmacies and pharmacists to file consolidated appeals for at least 30 business days after claim adjudication or maximum allowable cost updates and respond within 30 business days.

AT A GLANCE

This bill requires Medicaid managed care organizations and their pharmacy benefit managers to reimburse non-affiliated pharmacies or pharmacists at least the net effective reimbursement paid to affiliated providers for identical Medicaid drugs or services, barring evasive arrangements.

AT A GLANCE

This bill requires PSAOs, pharmacy switch companies, and rebate aggregators to register with the Department of Financial Services before operating in New York by March 31, June 30, and September 30, 2027, respectively.

The recent legislative changes significantly impact the regulation of pharmacy benefit managers (PBMs) in Wisconsin, focusing on enhancing transparency, fairness, and accessibility in pharmaceutical pricing and reimbursement practices. Key provisions require PBMs to pay pharmacies a professional dispensing fee that matches state medical assistance rates and prohibit them from imposing fees that would require remuneration from pharmacies. Additionally, PBMs must allow any licensed pharmacy to participate in their networks under the same terms and cannot charge different copayments based on network participation.

The legislation mandates that PBMs maintain and provide access to maximum allowable cost (MAC) lists, which must be updated promptly in response to price changes. Pharmacies are granted the right to appeal MAC determinations that fall below their acquisition costs, with PBMs required to resolve these appeals within a specified timeframe. Furthermore, PBMs are prohibited from discriminating against 340B covered entities and must ensure that all pharmacies in a preferred network are reimbursed at the same rates.

Auditing practices are also addressed, with requirements for uniformity in audits across similar pharmacies and restrictions on recouping reimbursements for errors that do not result in financial harm. PBMs must deliver final audit reports within a designated period and cannot retaliate against pharmacies for reporting violations or exercising their rights under the new regulations.

Health insurance policies are required to apply amounts paid for brand-name prescription drugs towards cost-sharing requirements, ensuring that patients' out-of-pocket expenses are minimized. Additionally, advanced written notice must be provided to enrollees regarding formulary changes, ensuring stability in medication options for those currently using affected drugs.

Overall, these changes aim to create a more equitable and transparent environment for pharmacies, pharmacists, and patients, significantly impacting the pharmacy and healthcare industries in Wisconsin.

The proposed legislation in Wisconsin aims to reform healthcare costs and prescription drug management, emphasizing affordability, transparency, and access to medications. Key provisions include eliminating cost-sharing for prescription drugs under the Medical Assistance program, capping insulin costs, and establishing a Prescription Drug Affordability Review Board to evaluate drug pricing and set upper payment limits for high-cost medications.

Pharmacy benefit managers (PBMs) will be subject to increased transparency requirements, including the disclosure of profits and financial details related to health plan sponsors. Insulin manufacturers will be mandated to create safety net programs to provide insulin to uninsured or underinsured individuals, ensuring access to medications at reduced costs. Additionally, the legislation introduces a prescription drug importation program to allow the importation of non-brand-name drugs from Canada, aimed at generating savings for residents.

The bill also focuses on diabetes treatment by mandating that disability insurance policies cover expenses for insulin infusion pumps and related supplies, with a cap of $35 for a one-month supply of insulin. The Department of Health Services will explore the implementation of a centralized drug repository program, while the Commissioner of Insurance will report on the progress of the prescription drug importation program.

To enhance oversight of prescription drug affordability, an Office of Prescription Drug Affordability will be created within the Commissioner of Insurance, supported by increased funding. This initiative seeks to improve access to affordable medications for consumers and ensure fair compensation for covered entities in the pharmaceutical industry. Overall, the legislation aims to enhance the operational framework for pharmacies and improve access to affordable prescription drugs for Wisconsin residents.

The proposed legislation introduces comprehensive reforms to the regulation of pharmacy benefit managers (PBMs) in Wisconsin, focusing on enhancing transparency, fairness, and accountability in the pharmaceutical supply chain. Key provisions require PBMs to pay pharmacies a professional dispensing fee that matches state rates and prohibit them from imposing various fees on pharmacies. Additionally, PBMs must allow any licensed pharmacy to participate in their networks under the same terms and conditions, ensuring equitable access for all pharmacies.

The legislation mandates that PBMs provide detailed maximum allowable cost lists to pharmacies, update these lists promptly, and establish an appeal process for pharmacies contesting low reimbursement rates. Furthermore, PBMs are required to notify enrollees of formulary changes well in advance and cannot remove drugs from formularies except at coverage renewal times. This aims to provide stability for patients regarding their medication options.

PBMs are also tasked with acting in the best interests of health benefit plan sponsors, including annual disclosures of profits and payments to consultants. They must remit payments for claims within 30 days and cannot discriminate against 340B covered entities in reimbursement practices. The legislation prohibits PBMs from retaliating against pharmacies for reporting violations or exercising their rights, fostering a more supportive environment for pharmacies.

Auditing practices are also addressed, requiring uniform standards for audits and prohibiting recoupments for errors that do not cause financial harm. The legislation aims to standardize reimbursement rates among pharmacies and protect pharmacies from unfair practices, ultimately benefiting consumers by improving access to pharmaceutical products.

Overall, these changes are designed to create a more transparent and equitable pharmaceutical landscape in Wisconsin, impacting the operations of PBMs, pharmacies, and health insurance providers significantly.

The proposed legislation establishes new requirements for employee benefit plan administrators, insurers of large group health benefit plans, and pharmacy benefit managers (PBMs) regarding the access and ownership of claims data by plan sponsors, such as employers. It mandates that contracts clearly state that plan sponsors own the claims data associated with their contracts, and such data cannot be sold without the consent of both the plan sponsor and the individual involved.

Plan sponsors or their designees are granted the right to request specific claims data and related information up to three times per plan year, covering periods of up to 24 months. Administrators and insurers are required to respond to these requests within seven business days. Additionally, detailed information about high-cost claims, defined as those exceeding $25,000 for non-pharmacy claims and $10,000 for pharmacy claims, must also be provided within the same timeframe.

PBMs are specifically required to furnish detailed data on prescription drug payments, rebate amounts, and claims within seven business days of a written request. They must also disclose any direct or indirect compensation paid to brokers or agents. The act prohibits PBMs from imposing excessive fees or conditions on information requests and ensures that claims data cannot be withheld if the plan sponsor attests to compliance with federal law regarding the use and disclosure of the information.

The legislation aims to enhance transparency in claims processing and costs, significantly impacting the health insurance and pharmacy benefit management industries. By improving access to critical claims data, the changes are expected to empower plan sponsors and potentially alter operational costs for PBMs and plan sponsors due to the new compliance requirements.

AT A GLANCE

This bill restricts pharmacy benefit managers to using maximum allowable cost reimbursement for qualifying drugs generally available in Utah and not obsolete, while requiring weekly updates, disclosures, and appeal-based corrections.

The bill adds Code Section 45-18-6.2 governing the state employees’ health insurance plan. On or after July 1, 2026, the Board of Community Health may not enter into, execute, or renew a plan-benefits contract with a pharmacy benefits manager that owns or has an ownership interest in a retail pharmacy, or with a legal entity that contracts with or uses such a pharmacy benefits manager.

The provision does not impair contracts that were in existence on June 30, 2026. Conflicting laws and parts of laws are repealed.

AT A GLANCE

This bill requires pharmacy benefit plan auditors, including PBMs, to apply uniform standards to licensed pharmacies and limits audits and recoupments through notice, appeals, and actual overpayments.

AT A GLANCE

This bill requires the Agency for Health Care Administration to establish an international prescription-drug reference-pricing system that caps cash pharmacy charges and insurer reimbursements at annually calculated reference prices.