SB 984

SECOND REGULAR SESSION
  SENATE COMMITTEE SUBSTITUTE FOR
 SENATE BILLS NOS. 984 & 968
  103RD GENERAL ASSEMBLY
 5297S.07C  KRISTINA MARTIN, Secretary
  AN ACT
 To repeal sections 338.600 and 376.387, RSMo, and to enact in lieu thereof four new sections
  relating to pharmacy benefits managers.
 Be it enacted by the General Assembly of the State of Missouri, as follows:
1Section  A.  Sections  338.600  and   376.387,     RSMo,      are
2  repealed and four new sections enacted in lieu thereof, to be
3  known as sections 338.600, 376.387, 376.394, and 376.399, to
4  read as follows:
1338.600.  1. As used in this section, the following
2  terms shall mean:
3(1)      "Audit", any review, inspection, investigation,
4  examination, or analysis conducted by a pharmacy benefits
5  manager (PBM) or its representative of a pharmacy's records,
6  claims, practices, or compliance with contractual
7  obligations or legal requirements, which may result in
8  recoupment, repayment demand, chargeback, penalty, or other
9  financial adjustment.  Routine verification or inquiry
10  regarding claim elements or documentation shall not
11  constitute an audit; however, no recoupment, repayment
12  demand, chargeback, penalty, or financial adjustment shall
13  be based upon or initiated through such inquiry unless the
14  inquiry is converted to an audit and conducted in compliance
15  with the requirements of this section;
 EXPLANATION-Matter enclosed in bold-faced brackets [thus] in this bill is not enacted
 and is intended to be omitted in the law.
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16(2)   "Entity", a managed care company, insurance
17 company or third-party payor, or representative of a managed
18 care company, insurance company or third-party payor, or a
19 pharmacy benefits manager or a subcontractor of a pharmacy
20 benefits manager.
212. Notwithstanding any other provision of law to the
22 contrary, when an audit of the records of a pharmacy
23 licensed in this state is conducted by a managed care
24 company, insurance company, third-party payor, or any entity
25 that represents such companies or groups, such audit shall
26 be conducted in accordance with the following:
27(1) The entity conducting the initial on-site audit
28 shall provide the pharmacy with notice at least [one week]
29 fourteen days prior to conducting the initial on-site audit
30 for each audit cycle and shall specify specific
31 prescriptions to be audited which may or may not include the
32 final two digits of the prescription numbers.    The notice
33 required under this subsection shall be in writing and shall
34 be sent by means that allows tracking of delivery to the
35 pharmacist or pharmacy not later than the fourteenth day
36 before the date on which the on-site audit is scheduled to
37 occur.   A pharmacy benefit manager is not required to
38 provide notice before conducting an audit if, after
39 reviewing claims data, written or oral statements of
40 pharmacy staff, wholesalers, or other investigative
41 information, including patient referrals, the plan issuer or
42 pharmacy benefit manager suspects the pharmacist or pharmacy
43 subject to the audit committed fraud or made an intentional
44 misrepresentation related to the pharmacy business, which
45 cause and suspicion shall be disclosed to pharmacy upon
46 initiation of the audit;
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47(2) Any audit which involves clinical judgment shall
48 be conducted by or in consultation with a [licensed]
49 pharmacist licensed by the Missouri board of pharmacy, and
50 said pharmacist shall be made available to the audited
51 pharmacy to discuss clinical rationale and Missouri legal
52 requirements;
53(3) Any clerical error, record-keeping error,
54 typographical error, or scrivener's error regarding a
55 required document or record shall not constitute fraud or
56 grounds for recoupment, so long as the prescription was
57 otherwise legally dispensed and the claim was otherwise
58 materially correct; except that, such claims may be
59 otherwise subject to recoupment of overpayments or payment
60 of any discovered underpayment.    No claim arising under this
61 subdivision shall be subject to criminal penalties without
62 proof of intent to commit fraud.   The pharmacy shall have
63 the right to submit amended claims within thirty days of the
64 discovery of an error to correct clerical or record keeping
65 errors in lieu of recoupment if the prescription was
66 dispensed according to requirements set forth in state or
67 federal law;
68(4) A pharmacy may use the records of a hospital,
69 physician, or other authorized practitioner of the healing
70 arts involving drugs or medicinal supplies written or
71 transmitted by any means of communication for purposes of
72 validating the pharmacy record with respect to orders or
73 refills of a legend or narcotic drug.    Electronically stored
74 images of prescriptions, electronically created annotations
75 and other related supporting documentation shall be
76 considered valid prescription records.   Hard copy and
77 electronic signature logs that indicate the delivery of
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78  pharmacy services shall be considered valid proof of receipt
79  of such services by a program enrollee;
80(5) A finding of an overpayment or underpayment may be
81  a projection based on the number of patients served and
82  having a similar diagnosis or on the number of similar
83  orders or refills for similar drugs; except that, recoupment
84  of claims shall be based on the actual overpayment or
85  underpayment unless the projection for overpayment or
86  underpayment is part of a settlement as agreed to by the
87  pharmacy;
88(6) Each pharmacy shall be audited under the same
89  standards and parameters as other pharmacies audited by the
90  entity;
91(7) A pharmacy shall be allowed at least thirty days
92  following receipt of the preliminary audit report in which
93  to produce documentation to address any discrepancy found
94  during an audit;
95(8) An audit shall be limited to forty unique
96  prescriptions, with a maximum of two hundred separately
97  adjudicated claims, that have been randomly selected, and
98  such randomness shall be reflected by auditing a similar
99  type of prescriptions as are collectively adjudicated.
100(a)   If an audit reveals the necessity for a review of
101 additional claims, the audit shall be conducted on site.
102(b)   An entity shall not initiate an audit of a
103 pharmacy more than two times in a calendar year, unless
104 fraud is suspected as described in subdivision (1) of this
105 subsection; such audit of pharmacy records includes any
106 prescription information request by an auditing entity that
107 could result in recoupment.
108(c)   The list of the claims subject to an on-site audit
109 shall be provided in the notice under paragraph (a) of this
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110 subdivision to the pharmacist or pharmacy and shall identify
111 the claims only by the prescription numbers or a date range
112 for prescriptions subject to the audit.     The last two digits
113 of the prescription numbers provided may be omitted;
114(9)    A recoupment shall not be based on a requirement
115 that a pharmacy or pharmacist perform a professional duty in
116 addition to or exceeding professional duties prescribed by
117 the Missouri board of pharmacy;
118(10)    Recoupment shall only occur following the
119 correction of a claim and shall be limited to amounts
120 adjudicated by a pharmacy benefits manager;
121(11)    Except for MO HealthNet claims, approval of drug,
122 prescriber, or patient eligibility upon adjudication of a
123 claim shall not be reversed unless the pharmacy or
124 pharmacist obtained the adjudication by fraud, waste, or
125 abuse, a misrepresentation of claim elements, or claims that
126 were not properly rendered or billed by a pharmacy or
127 pharmacist, or otherwise in accordance with state pharmacy
128 audit laws.
129(a)    This subdivision does not preclude a pharmacy
130 benefits manager from engaging in claims reconciliation
131 activities relating to brand effective rates and generic
132 effective rates if:
133a.    They are identified and agreed to in contract; and
134b.    The activities do not result in a retroactive
135 reduction or recoupment of payment to the pharmacist or
136 pharmacy for a previously adjudicated covered claim.
137(b)    A pharmacy benefits manager may not charge a
138 pharmacy or pharmacist a fee relating to the adjudication of
139 a claim;
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140(12)   Any entity conducting an audit shall not be
141 compensated, nor shall any of its employees be compensated,
142 directly or indirectly, based on any amounts recouped;
143(13)   An entity shall not charge a fee for conducting
144 an on-site or a desk audit unless there is a finding of
145 actual fraud;
146(14) The period covered by the audit shall not exceed
147 a two-year period beginning [two years prior to the initial
148 date of the on-site portion of the audit unless otherwise
149 provided by contractual agreement or if] the date the claim
150 was submitted for payment there has been a previous finding
151 of fraud or as otherwise provided by state or federal law;
152[(9)] (15)    An audit shall not be initiated or
153 scheduled during the first [three] five business days of any
154 month due to the high volume of prescriptions filled during
155 such time unless otherwise consented to by the pharmacy;
156[(10)] (16)   The preliminary audit report shall be
157 delivered to the pharmacy within one hundred twenty days
158 after conclusion of the audit, with reasonable extensions
159 permitted. A final audit report shall be delivered to the
160 pharmacy within six months of receipt by the pharmacy of the
161 preliminary audit report or final appeal, as provided for in
162 subsection 3 of this section, whichever is later.        Audit
163 reports not delivered to the pharmacy in this time line
164 shall be deemed to have no discrepancies and no recoupment
165 shall be made;
166[(11)] (17)   Notwithstanding any other provision in
167 this subsection, the entity conducting the audit shall not
168 use the accounting practice of extrapolation in calculating
169 recoupments or penalties for audits, except as otherwise
170 authorized under subdivision (5) of this subsection;
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171(18)    The days' supply for unit-of-use items, such as
172 topicals, drops, vials, and inhalants, shall not be limited
173 beyond manufacturer recommendations;
174(19)    If the only commercially available package size
175 exceeds an entity's maximum days' supply, the dispensing of
176 such package size shall be accepted by the entity and shall
177 not be the basis for recoupment;
178(20)    If the only commercially available package size
179 exceeds an entity's maximum days' supply and the entity
180 accepts the refill of such prescription, the entity shall
181 not recoup such claim as an early refill;
182(21)    The failure of a pharmacy to collect a copayment
183 shall not be the basis for recoupment if the pharmacy
184 provides documentation of billing of the claim and a
185 reasonable attempt to collect the copayment; and
186(22)    In a wholesale invoice audit conducted by an
187 entity:
188(a)    An entity shall not audit the claims of another
189 entity;
190(b)    The following shall not form the basis for
191 recoupment:
192a.    The national drug code for the dispensed drug is in
193 a quantity that is a sub-unit or multiple of the purchased
194 drug as reflected on a supporting wholesale invoice;
195b.    The correct quantity dispensed is reflected on the
196 audited pharmacy claim; or
197c.    The drug dispensed by the pharmacy on an audited
198 pharmacy claim is identical to the strength and dosage form
199 of the drug purchased;
200(c)    The entity shall accept as evidence:
201a.    Supplier invoices issued prior to the date of
202 dispensing the drug underlying the audited claim;
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203b.    Invoices from any supplier authorized by law to
204 transfer ownership of the drug acquired by the audited
205 pharmacy;
206c.    Copies of supplier invoices in the possession of
207 the audited pharmacy; and
208d.    Reports required by any state board or agency; and
209(d)    Within five business days of a request by the
210 audited pharmacy, the entity shall provide supporting
211 documentation provided to the entity by the audited
212 pharmacy's suppliers.
213[2.] 3. Recoupments of any disputed moneys shall only
214 occur after final internal disposition of the audit,
215 including the appeals process set forth in subsection 3 of
216 this section.       Should the identified discrepancy for an
217 individual audit exceed twenty-five thousand dollars, future
218 payments to the pharmacy in excess of twenty-five thousand
219 dollars may be withheld pending finalization of the audit.
220[3.] 4. Each entity conducting an audit shall
221 establish an appeals process, lasting no longer than six
222 months, under which a licensed pharmacy may appeal an
223 unfavorable preliminary audit report to the entity.       If,
224 following such appeal, the entity finds that an unfavorable
225 audit report or any portion thereof is unsubstantiated, the
226 entity shall dismiss the audit report or such portion
227 without the necessity of any further proceedings.
228[4.] 5. Each entity conducting an audit shall provide
229 a copy of the final audit report, after completion of any
230 appeal process, to the plan sponsor.       Such report shall
231 include the total amount of recoupment returned to the plan
232 sponsor, if any.
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233[5.] 6. This section shall not apply to any
234 investigative audit that involves probable fraud, willful
235 misrepresentation, or abuse.
236[6.] 7. This section shall not apply to any audit
237 conducted as part of any inspection or investigation
238 conducted by any governmental entity or law enforcement
239 agency.
1376.387.      1. For purposes of this section, the
2  following terms shall mean:
3(1) ["Covered person", the same meaning as such term
4  is defined in section 376.1257] "Contracted pharmacy", a
5  pharmacy located in Missouri participating in the network of
6  a pharmacy benefits manager through a direct or indirect
7  contract;
8(2) ["Health benefit plan", the same meaning as such
9  term is defined in section 376.1350;
10(3)]   "Health carrier" [or "carrier", the same meaning
11  as such term is defined in section 376.1350], an entity
12  subject to the insurance laws and regulations of this state
13  that contracts or offers to contract to provide, deliver,
14  arrange for, pay for, or reimburse any of the costs of
15  health care services, including a sickness and accident
16  insurance company, a health maintenance organization, a
17  nonprofit hospital and health service corporation, or any
18  other entity providing a plan of health insurance, health
19  benefits, or health services, except that such plan shall
20  not include any coverage pursuant to a liability insurance
21  policy, workers' compensation insurance policy, or medical
22  payments insurance issued as a supplement to a liability
23  policy;
24(3)    "Maximum allowable cost", the per-unit amount that
25  a pharmacy benefits manager reimburses a pharmacist for a
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26 prescription drug, excluding a dispensing or professional
27 fee;
28(4)   "Maximum allowable cost list" or "MAC list", a
29 listing of drug products that meet the standard described in
30 this section;
31[(4)] (5)    "Pharmacy", the same meaning as such term is
32 defined in chapter 338;
33[(5)] (6)    "Pharmacy benefits manager", [the same
34 meaning as such term is defined in section 376.388] an
35 entity that contracts with pharmacies on behalf of health
36 carriers or health benefit plans to provide prescription
37 drug and pharmacist services;
38(7)   "Pharmacy benefits manager affiliate", a pharmacy
39 or pharmacist that directly or indirectly, through one or
40 more intermediaries, owns or controls, is owned or
41 controlled by, or is under common ownership or control with
42 a pharmacy benefits manager.
432. [No pharmacy benefits manager shall include a
44 provision in a contract entered into or modified on or after
45 August 28, 2018, with a pharmacy or pharmacist that requires
46 a covered person to make a payment for a prescription drug
47 at the point of sale in an amount that exceeds the lesser of:
48(1) The copayment amount as required under the health
49 benefit plan; or
50(2) The amount an individual would pay for a
51 prescription if that individual paid with cash.
523. A pharmacy or pharmacist shall have the right to
53 provide to a covered person information regarding the amount
54 of the covered person's cost share for a prescription drug,
55 the covered person's cost of an alternative drug, and the
56 covered person's cost of the drug without adjudicating the
57 claim through the pharmacy benefits manager.      Neither a
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58 pharmacy nor a pharmacist shall be proscribed by a pharmacy
59 benefits manager from discussing any such information or
60 from selling a more affordable alternative to the covered
61 person.
624. No pharmacy benefits manager shall, directly or
63 indirectly, charge or hold a pharmacist or pharmacy
64 responsible for any fee amount related to a claim that is
65 not known at the time of the claim's adjudication, unless
66 the amount is a result of improperly paid claims or charges
67 for administering a health benefit plan.
685. This section shall not apply with respect to claims
69 under Medicare Part D, or any other plan administered or
70 regulated solely under federal law, and to the extent this
71 section may be preempted under the Employee Retirement
72 Income Security Act of 1974 for self-funded employer-
73 sponsored health benefit plans.
746. A pharmacy benefits manager shall notify in writing
75 any health carrier with which it contracts if the pharmacy
76 benefits manager has a conflict of interest, any commonality
77 of ownership, or any other relationship, financial or
78 otherwise, between the pharmacy benefits manager and any
79 other health carrier with which the pharmacy benefits
80 manager contracts.
817. The department of commerce and insurance shall
82 enforce this section] Upon each contract execution or
83 renewal between a pharmacy benefits manager and a pharmacy
84 or between a pharmacy benefits manager and a pharmacy's
85 contracting representative or agent, such as a pharmacy
86 services administrative organization, a pharmacy benefits
87 manager shall, with respect to such contract or renewal:
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88(1)    Include in such contract or renewal the sources
89  utilized to determine maximum allowable cost and update such
90  pricing information at least every seven days; and
91(2)    Maintain a procedure to eliminate products from
92  the maximum allowable cost list of drugs subject to such
93  pricing or modify maximum allowable cost pricing at least
94  every seven days, if such drugs do not meet the standards
95  and requirements of this section, in order to remain
96  consistent with pricing changes in the marketplace.
973.    A pharmacy benefits manager shall reimburse
98  pharmacies for drugs subject to maximum allowable cost
99  pricing that has been updated to reflect market pricing at
100 least every seven days as set forth under subdivision (1) of
101 subsection 2 of this section.
1024.    A pharmacy benefits manager shall not place a drug
103 on a maximum allowable cost list unless there are at least
104 two therapeutically equivalent multisource generic drugs, or
105 at least one generic drug available from at least one
106 manufacturer, generally available for purchase by network
107 pharmacies from national or regional wholesalers.
1085.    All contracts between a pharmacy benefits manager
109 and a contracted pharmacy or between a pharmacy benefits
110 manager and a pharmacy's contracting representative or
111 agent, such as a pharmacy services administrative
112 organization, shall include a process to internally appeal,
113 investigate, and resolve disputes regarding maximum
114 allowable cost pricing.     The process shall include the
115 following:
116(1)    The right to appeal shall be limited to fourteen
117 calendar days following the reimbursement of the initial
118 claim; and
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119(2)    A requirement that the pharmacy benefits manager
120 shall respond to an appeal described in this subsection no
121 later than fourteen calendar days after the date the appeal
122 was received by such pharmacy benefits manager.
1236.    For appeals that are denied, the pharmacy benefits
124 manager shall provide the reason for the denial and identify
125 the national drug code of a drug product that may be
126 purchased by contracted pharmacies at a price at or below
127 the maximum allowable cost and, when applicable, may be
128 substituted lawfully.
1297.    If the appeal is successful, the pharmacy benefits
130 manager shall:
131(1)    Adjust the maximum allowable cost price that is
132 the subject of the appeal effective on the day after the
133 date the appeal is decided;
134(2)    Apply the adjusted maximum allowable cost price to
135 all similarly situated pharmacies as determined by the
136 pharmacy benefits manager; and
137(3)    Allow the pharmacy that succeeded in the appeal to
138 reverse and rebill the pharmacy benefits claim giving rise
139 to the appeal.
1408.    Appeals shall be upheld if:
141(1)    The pharmacy being reimbursed for the drug subject
142 to the maximum allowable cost pricing in question was not
143 reimbursed as required under subsection 3 of this section; or
144(2)    The drug subject to the maximum allowable cost
145 pricing in question does not meet the requirements set forth
146 under subsection 4 of this section.
1479.    A pharmacy benefits manager shall provide plan
148 sponsors with such plan sponsor's pharmacy claims data as
149 reasonably requested by a plan sponsor.
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15010.   The pharmacy benefits manager or plan sponsor
151 shall provide the plan sponsor and department of commerce
152 and insurance documentation of any benefit design that
153 encourages or requires enrollees to fill prescriptions at
154 affiliated pharmacies.
15511.   A pharmacy benefits manager shall exercise good
156 faith and fair dealing in the administration of pharmacy
157 benefits and shall ensure that any conflicts of interest
158 that may clinically or financially impact covered patients
159 or the health benefit plan sponsor in a negative manner are
160 disclosed.
16112.   All disclosures required under this section shall
162 be provided to the plan sponsor or its authorized agent in a
163 universal manner.
16413.   If a pharmacy benefits manager or health plan has
165 an affiliated pharmacy or a pharmacy under common ownership,
166 the pharmacy benefits manager shall disclose to the plan
167 sponsor and the department of commerce and insurance:
168(1)   The amount charged per dosage unit to the
169 affiliated pharmacy; and
170(2)   The median amount charged per dosage unit at non
171 affiliated, in-network pharmacies.
17214.   The department of commerce and insurance may audit
173 pharmacy benefits manager to ensure compliance with this
174 section.
1376.394.      1. As used in this section, the following
2  terms shall mean:
3(1)   "Acquisition cost", the set of National Average
4  Drug Acquisition Costs, "NADAC", as calculated by the
5  Centers for Medicare and Medicaid Services and reflected in
6  the most recently released public file;
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7(2)    "Critical access care pharmacy", a Missouri-
8 domiciled pharmacy with a physical location in the state of
9 Missouri that employs less than five hundred employees
10 across common ownership which is:
11(a)    Located in a county or city with fewer than fifty
12 thousand residents; or
13(b)    In a county or city with fifty thousand or more
14 residents and in an area within Missouri that is designated
15 as a Primary Care or Mental Health Health Professional
16 Shortage Area (HPSA) or a Medically Underserved Area by the
17 Health Resources and Services Administration (HRSA), an
18 agency of the U.S. Department of Health and Human Services;
19 or
20(c)    Any essential pharmacy as defined in Section 1860D-
21 42 of the Social Security Act, 42 U.S.C. 1395-152;
22(3)    "Similarly situated", a critical access care
23 pharmacy:
24(a)    That is in any of the pharmacy benefits manager's
25 networks;
26(b) That purchases the particular drug or medical
27 product or device to which the finding applies from the same
28 pharmaceutical wholesaler as the pharmacy that prevailed in
29 the appeal; and
30(c)    To which the pharmacy benefits manager also
31 applies the challenged rate of reimbursement or actual cost.
322.    Notwithstanding any provision of law to the
33 contrary, a pharmacy benefits manager shall not reimburse a
34 critical access care pharmacy for a prescription drug or
35 device an amount that is less than the actual cost to that
36 pharmacy for the prescription drug or device.
37(1)    A pharmacy benefits manager shall establish a
38 process for a pharmacy to appeal a reimbursement for failing
SCS SBs 984 & 968  16
39 to pay at least the actual cost and dispensing fee to the
40 critical access care pharmacy for the prescription drug or
41 device and shall permit a critical access care pharmacy or
42 its designated agent to file an appeal using the standard
43 appeal form described in this section.
44(2)    If a critical access care pharmacy chooses to
45 contest a reimbursement for failing to pay at least the
46 actual cost the critical access care pharmacy incurred for a
47 particular drug or medical product or device, then the
48 critical access care pharmacy has the right to designate a
49 pharmacy services administrative organization or other agent
50 to file and handle its appeal.
51(3)    The department of commerce and insurance shall
52 create and make available to pharmacy benefits managers and
53 covered entities a standard form to be used by a critical
54 access care pharmacy or its designated agent to file an
55 appeal pursuant to this subsection with a pharmacy benefits
56 manager or covered entity.
573.    If a critical access care pharmacy or agent acting
58 on behalf of a critical access care pharmacy prevails in an
59 appeal provided for in this section, then within seven
60 business days after notice of the appeal is received by the
61 pharmacy benefits manager or covered entity, the pharmacy
62 benefits manager or covered entity shall:
63(1)    Make the necessary change to the challenged rate
64 of reimbursement or actual cost;
65(2)    If the product involved in the appeal is a drug,
66 provide to the critical access care pharmacy or agent the
67 national drug code number for the drug on which the change
68 is based;
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69(3)    Permit the challenging critical access care
70  pharmacy to reverse and rebill the claim upon which the
71  appeal is based;
72(4)    Pay or waive the cost of any transaction fee
73  required to reverse and rebill the claim;
74(5)    Reimburse the critical access care pharmacy at
75  least in an amount equal to the critical access care
76  pharmacy's actual cost for the prescription drug or device;
77  and
78(6)    Apply the findings from the appeal as to the rate
79  of reimbursement and actual cost for the particular drug or
80  medical product or device to other similarly situated
81  critical access care pharmacies.
824.    It is a violation of this section if, after an
83  appeal in which a pharmacy or agent acting on behalf of a
84  critical access care pharmacy prevails, a pharmacy benefits
85  manager or covered entity fails to reimburse the critical
86  access care pharmacy at least actual cost.
875.    If a critical access care pharmacy or agent acting
88  on behalf of a critical access care pharmacy loses or is
89  denied an appeal provided for in this section, then:
90(1)    If the product associated with the national drug
91  code number or unique device identifier is available at a
92  cost that is less than the challenged rate of reimbursement
93  from a pharmaceutical wholesaler in this state, then within
94  seven business days after notice of the appeal is received
95  by the pharmacy benefits manager or covered entity, the
96  pharmacy benefits manager or covered entity shall provide
97  the appealing critical access care pharmacy or agent with:
98(a)    The name of the national or regional
99  pharmaceutical wholesalers operating in this state that have
100 the particular drug or medical product or device currently
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101 in stock at a price that is less than the amount of the
102 challenged rate of reimbursement; and
103(b)    If the product involved in the appeal is a drug,
104 then the national drug code number for the drug; or
105(c)    If the product involved is a medical device, then
106 the unique device identifier for the device; and
107(2)    If the product associated with the national drug
108 code number or unique device identifier is not available at
109 a cost that is less than the challenged rate of
110 reimbursement from the pharmaceutical wholesaler from whom
111 the critical access care pharmacy purchases the majority of
112 prescription pharmaceutical products for resale, then the
113 pharmacy benefits manager shall adjust the challenged rate
114 of reimbursement to an amount equal to or greater than the
115 appealing critical access care pharmacy's actual cost and
116 permit the critical access care pharmacy to reverse and
117 rebill each claim affected by the inability to procure the
118 pharmaceutical product at a cost that is equal to or less
119 than the previously challenged rate of reimbursement. The
120 pharmacy benefits manager shall pay or waive the cost of any
121 transaction fee required to reverse and rebill the claim.
1226.    The department of commerce and insurance shall
123 enforce this section.
1376.399.      1. Health benefit plans beginning on or
2  after January 1, 2027 shall comply with H.R. 7148, the
3  Consolidated Appropriations Act, 2026.
42.    For plan years beginning on or after January 1,
5  2027, no contract or arrangement or renewal or extension of
6  a contract or arrangement, entered into on or after January
7  1, 2027, for services between a covered plan and a covered
8  service provider, or between a sponsor of a covered plan and
9  a covered service provider, through a health insurance
SCS SBs 984 & 968  19
10 issuer offering group health insurance coverage, a third-
11 party administrator, an entity providing pharmacy benefit
12 management services, or other entity, for pharmacy benefit
13 management services, is reasonable within the meaning of
14 this section unless such entity providing pharmacy benefit
15 management services:
16(1)   Remits one hundred percent of rebates, fees,
17 alternative discounts, and other remuneration received from
18 any applicable entity that are related to utilization of
19 drugs or drug spending under such health plan or health
20 insurance coverage, to the group health plan or, in the case
21 of a health insurance issuer offering group health insurance
22 coverage in connection with a group health plan, to the
23 health insurance issuer offering group health insurance
24 coverage on behalf of the plan; and
25(2)   Does not enter into any contract for pharmacy
26 benefit management services on behalf of such a plan or
27 coverage, with an applicable entity unless one hundred
28 percent of rebates, fees, alternative discounts, and other
29 remuneration received under such contract that are related
30 to the utilization of drugs or drug spending under such
31 group health plan or health insurance coverage are remitted
32 to the group health plan or, in the case of a health
33 insurance issuer offering group health insurance coverage in
34 connection with a group health plan, to the health insurance
35 issuer on behalf of the plan by the entity providing
36 pharmacy benefit management services.
37 Nothing this subsection shall be construed to affect the
38 term of a contract or arrangement, as in effect on January
39 1, 2027, except that such subdivision shall apply to any
40 renewal or extension of such a contract or arrangement
SCS SBs 984 & 968  20
41 entered into on or after such effective date, as so
42 described.
433.    With respect to such rebates, fees, alternative
44 discounts, and other remuneration, the rebates, fees,
45 alternative discounts, and other    remuneration under this
46 section shall be remitted:
47(1)    On a quarterly basis, to the group health plan or,
48 in the case of a health insurance issuer offering group
49 health insurance coverage in connection with a group health
50 plan, to the group health insurance issuer on behalf of the
51 plan, not later than ninety days after the end of each
52 quarter; or
53(2)    In the case of an underpayment in a remittance for
54 a prior quarter, as soon as practicable, but not later than
55 ninety days after notice of the underpayment is first given;
56(3)    Fully disclosed and enumerated to the group health
57 plan or health insurance issuer; and
58(4)    Returned to the covered service provider for
59 pharmacy benefit management services on behalf of the group
60 health plan if any audit by a plan sponsor, issuer or a
61 third party designated by a plan sponsor, indicates that the
62 amounts received are in excess of correct amounts after such
63 amounts have been paid to the group health plan, in the
64 amount of such excess.
654.    The department of commerce and insurance shall
66 enforce this section and shall have the right to any
67 information in the section from any pharmacy benefits
68 manager under investigation individually or in aggregate per
69 their request.
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