HB 1236

ENROLLED
 2026 Regular Session
  ACT No. 913
 HOUSE BILL NO. 1236  (Substitute for House Bill No. 866 by Representative Dewitt)
 BY REPRESENTATIVES DEWITT AND ECHOLS
1AN ACT
2 To amend and reenact R.S. 22:1868(B)(introductory paragraph), (1), and (4) and (C)(1), (2),
3and (3)(c) and (d), to enact R.S. 22:1868(B)(5), (D), and (E), and to repeal R.S.
422:1868(B)(2), relative to pharmacy benefit managers; to provide for definitions; to
5provide for pharmacy reimbursements; to prohibit certain reimbursement cost
6assignments; to provide for certain prohibitions; to provide for an effective date; to
7provide for retroactive application; and to provide for related matters.
8 Be it enacted by the Legislature of Louisiana:
9Section 1. R.S. 22:1868(B)(introductory paragraph), (1), and (4) and (C)(1), (2), and
10 (3)(c) and (d) are hereby amended and reenacted and R.S. 22:1868(B)(5), (D), and (E) are
11 hereby enacted to read as follows:
12§1868. Local pharmacy reimbursement; National Average Drug Acquisition Costs;
13appeals
14*       *  *
15B. For purposes of this Section, the following definitions shall apply:
16(1)(a)    "Acquisition cost" means the set of National Average Drug
17Acquisition Costs, "NADAC", as calculated by the Centers for Medicare and
18Medicaid Services and reflected in the most recently released public file. means the
19amount a local pharmacy actually pays to purchase a prescription drug or device, as
20evidenced by a wholesaler or manufacturer invoice, and shall not be less than the
21National Average Drug Acquisition Cost or NADAC published by the Centers for
22Medicare and Medicaid Services on the date the prescription drug is dispensed.
23(b) For drugs for which no NADAC rate is published, acquisition cost means
24the local pharmacy's documented invoice cost or, if no invoice is available, the
25wholesale acquisition cost as published in a nationally recognized drug pricing
26compendium on the date of dispensing.
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 HB NO. 1236  ENROLLED
1(c) "Acquisition cost" is not defined by or determined at the sole discretion
2of a pharmacy benefit manager or third-party administrator.
3*       *  *
4(4) "Reimbursement formula" means a prescription drug reimbursement
5calculation involving an ingredient price, calculated based on a prescription drug
6pricing benchmark plus an adjustment factor, and a professional dispensing fee.
7(5) "Professional dispensing fee" means a fee that meets all of the following:
8(a) Incurred at the point of sale or service and pays for costs in excess of the
9ingredient cost of a covered outpatient drug each time a covered outpatient drug is
10dispensed.
11(b) Includes only pharmacy costs associated with ensuring that possession
12of the appropriate covered outpatient drug is transferred to a beneficiary. Pharmacy
13costs include but are not limited to reasonable costs associated with a pharmacist's
14time in checking the computer for information about an individual's coverage,
15performing drug utilization review and preferred drug list review activities,
16measurement or mixing of the covered outpatient drug, filling the container,
17beneficiary counseling, and physically providing the completed prescription to the
18beneficiary, delivery, special packaging, and overhead associated with maintaining
19the facility and equipment necessary to operate the pharmacy.
20(c) Does not include administrative costs incurred by the state in the
21operation of the covered outpatient drug benefit including systems costs for
22interfacing with pharmacies.
23C. Notwithstanding any provision of law to the contrary, effective January
241, 2026, a pharmacy benefit manager shall meet all of the following requirements for
25claims submitted by any local pharmacy to a pharmacy benefit manager
26administering claims on behalf of a health plan, except for the Office of Group
27Benefits:
28(1) Adopt a reimbursement formula using either NADAC as the prescription
29drug pricing benchmark or, if NADAC is not available, the wholesale acquisition
30cost. or, with prior written approval by the commissioner, an alternative prescription
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 HB NO. 1236  ENROLLED
1drug pricing benchmark that results in claim payment errors that are both comparable
2to or less than NADAC in terms of frequency and smaller than NADAC in terms of
3magnitude.
4(2)(a) Adopt a reimbursement formula using an adjustment factor that, based
5on claims experience data available to the pharmacy benefit manager, is reasonably
6expected to result in a claim payment error rate of no more than two percent per drug
7as identified by its national drug code. a professional dispensing fee that is an
8amount not less than the professional dispensing fee established by the Louisiana
9Department of Health for the Louisiana Medicaid program.
10(b) The professional dispensing fee shall reflect the actual costs of the
11professional services provided by the pharmacists and expenses related to the
12physical act of dispensing.
13(3) Adopt an appeal process for pharmacists to challenge claim payment
14errors that, at a minimum, meets all of the following requirements:
15*       *  *
16(c) If an appeal is filed with the pharmacy benefit manager, the pharmacy
17must shall include a written invoice from the wholesaler that includes the drug name,
18national drug code number, purchase date, and cost of the drug.
19(d) If a claim payment error occurred, the pharmacy benefit manager shall
20make an additional payment to the pharmacy to increase the reimbursement amount
21to the acquisition cost. The pharmacy benefit manager is prohibited from amending
22or changing the amount a prescription drug consumer must pay for an out-of-pocket
23cost share or expense.
24*       *  *
25D. The reimbursement formula adopted by a pharmacy benefit manager
26pursuant to this Section shall include the professional dispensing fee required by this
27Section as a non-recoverable cost. The pharmacy benefit manager shall not collect,
28recoup, or recover the professional dispensing fee from any pharmacy, pharmacist,
29or member.
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1E. The commissioner may require submission of claims-level data, including
2but not limited to reimbursement amounts, dispensing fees, and any adjustments for
3the purpose of verifying compliance with this Section.
4Section 2. R.S. 22:1868(B)(2) is hereby repealed in its entirety.
5Section 3. The provisions of this Act shall be given prospective and retroactive
6 application. The provisions of Subsection D shall be applied retroactively to January 1, 2026.
7 A pharmacy benefit manager shall be deemed compliant with this retroactive application
8 upon demonstration that it has adopted and reprocessed all applicable claims retroactively
9 to January 1, 2026, using a reimbursement formula which includes the prescription drug
10 pricing benchmark described in R.S. 22:1868(C)(1) as amended herein plus a professional
11 dispensing fee that is an amount no less than nine dollars. The reimbursement formula shall
12 also apply prospectively and the deemed compliance applicable to the retroactive application
13 shall not be construed to apply to the prospective application of this Act. All other
14 provisions of this Act shall apply prospectively only.
15Section 4. This Act shall become effective upon signature by the governor or, if not
16 signed by the governor, upon expiration of the time for bills to become law without signature
17 by the governor, as provided by Article III, Section 18 of the Constitution of Louisiana. If
18 vetoed by the governor and subsequently approved by the legislature, this Act shall become
19 effective on the day following such approval.
  SPEAKER OF THE HOUSE OF REPRESENTATIVES
  PRESIDENT OF THE SENATE
  GOVERNOR OF THE STATE OF LOUISIANA
 APPROVED:
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