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Legislative Year: 2021 Change
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Bill Detail: HB21-1297

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Title Pharmacy Benefit Manager And Insurer Requirements
Status Governor Signed (07/06/2021)
Bill Subjects
  • Health Care & Health Insurance
House Sponsors E. Hooton (D)
P. Will (R)
Senate Sponsors J. Sonnenberg (R)
J. Buckner (D)
House Committee Health and Insurance
Senate Committee State, Veterans and Military Affairs
Date Introduced 04/28/2021
Summary

The bill precludes a health insurer, a pharmacy benefit manager
(PBM), or an entity acting for a health insurer or PBM to conduct on-site
audits of pharmacies within 12 months after a prior on-site audit except
in specified circumstances.
Additionally, the bill enacts the Pharmacy Fairness Act (act),
which imposes requirements regarding contracts between PBMs and

pharmacies as follows:
  • Requires a health insurer to submit to the commissioner of
insurance (commissioner) a list of PBMs the health insurer
uses to manage or administer prescription drug benefits
under its health benefit plans offered in this state;
  • Prohibits PBMs from:
  • Restricting a covered person's access to prescription
drug benefits at an in-network retail pharmacy,
except as permitted in limited circumstances;
  • Charging a pharmacy or pharmacist a fee for
adjudicating a claim, other than a one-time fee of
not more than the lesser of 25% of the pharmacy
dispensing fee or 25 cents for receipt and processing
of the same pharmacy claim;
  • Requiring stricter pharmacy accreditation standards
or certification requirements than the standards or
requirements that are applicable to similarly situated
PBM-affiliated pharmacies within the same PBM
network; or
  • Refusing to designate a pharmacy located in a
county with a population of 20,000 or fewer as a
preferred pharmacy under the health benefit plan.
A PBM that administers the drug assistance program operated by
the department of public health and environment is exempt from the
requirements and prohibitions of the act with regard to the PBM's
administration of that program only.
The bill also:
  • Requires a health insurer or PBM to respond in real time to
a request from an insured, the insured's health care
provider, or a third party acting on behalf of the insured or
provider for data regarding the cost, benefits, and coverage
under the insured's health benefit plan for a particular drug;
and
  • Requires a health insurer or PBM that removes a
prescription drug from the prescription drug formulary or
moves a prescription drug to a higher cost tier on the
formulary during the benefit year to notify a covered
person that is prescribed that drug at least 30 days before
the action and allow the covered person to continue using
the drug without prior authorization and at the same
coverage level for the remainder of the benefit year, except
in specified circumstances.

Committee Reports
with Amendments
Full Text
Full Text of Bill (pdf) (most recent)
Fiscal Notes Fiscal Notes (09/27/2021) (most recent)  
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