PBM Prohibitions Included In Proposed Law

House Bill 4287 has been introduced in the House of Delegates to prevent pharmacy benefit managers (PBMs) from imposing certain contractual provisions with pharmacies.  The bill also prohibits PBMs from posting logos of pharmacies on medical or prescription drug cards distributed consumers.

This legislation is sought by the West Virginia Pharmacists Association.   Pharmacists are requested to contact their Delegates and Senators in the West Virginia Legislature and request they support this important legislation.    Below is text of the proposed law.

“(a)  Allowable claim amount” means the amount the health carrier or pharmacy benefits manager has agreed to pay the pharmacy for the prescription medication.

“(b)  A pharmacy benefit manager may not charge a pharmacist or pharmacy a fee related to the adjudication of a claim including:

(1)  The receipt and processing of a pharmacy claim;

(2)  The development or management of a claim processing or adjudication network; or

(3)  Participation in a claim processing or claim adjudication network.

“(c)  A contract between a health care provider and a pharmacy benefit manager 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 carriers to health care providers.

“(d)  No health carrier or pharmacy benefit manager shall require an individual to make a payment a the point of sale for a covered prescription medication in an amount greater than the lesser of:

“(1)  The applicable copayment for such prescription medication;

“(2)  The allowable claim amount for the prescription medication; or

“(3)  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.

“(e)  If a contract contains a provision prohibited under this section, the provision shall be void and unenforceable.  The invalidity or unenforceability of any contract provision under this subsection shall not affect any other provision of the contract.

“(f)  A pharmacy benefit manager may not place a trademark or logo on a medical and prescription drug card.”

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