Legislative Proposal: “Regulation of Pharmacy Benenfit Managers”

Below is proposed legislation to be introduced in the WV Legislature to further regulate pharmacy benefit managers.   WVPA Executive Director Richard Stevens consulted members of the legislature and their attorneys regarding the need for this legislation and provisions that should be included in the proposed law.

The proposed legislation defines “allowable claim amount” as the amount the health insurance carrier or pharmacy benefits manager (PBM) has agreed to pay the pharmacy for the prescription medication.

A PBM may not charge a pharmacist or pharmacy a fee related to the adjudication of a claim including: (a) the receipt and processing of a pharmacy claim; (b) the development or management of a claim processing or adjudication network; or (c) participation in a claim processing or claim adjudication network.

A contract between a pharmacist or pharmacy and a PBM may not contain a provision prohibiting disclosure of billed or allowed amounts, reimbursement rates or out-of-pocket costs, to assist consumers and institutional purchasers in making informed decisions regarding their health care and informed choices among health care providers and allow comparisons between prices paid by various health insurance carriers to health care providers.

No insurance company or PBM shall require an individual to make a payment at the point of sale for a covered prescriptions medication in an amount greater than the lesser of: (a) the applicable copayment for such prescription medication; (b) the allowable claim amount for the prescription medication; or (c) the amount an individual would pay for the prescription medication if the individual purchased the prescription medication without using a health benefit plan, or any other source of prescription medication benefits or discounts.

If a contract contains a provision prohibited under this new law, that provision shall be void and unenforceable.

A PBM may not imprint a trademark or logo on a medical or prescription drug card.