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Committee advances Senate Bill 140 with amendments targeting PBM practices, pharmacy reimbursement and network adequacy
Summary
A committee unanimously approved an amended Senate Bill 140 that removes vertical-integration language but sets pharmacy network standards, bans certain clawbacks, requires reimbursement parity, and guarantees minimum reimbursements tied to NADAC and a Medicaid dispensing fee for some pharmacies.
A House committee voted 13-0 to pass an amended version of Senate Bill 140 that changes how pharmacies are reimbursed, limits certain pharmacy benefit manager (PBM) practices and requires network adequacy for in-person pharmacy access.
Representative Layman, who presented amendments adopted in committee, said the bill removes the Senate's vertical-integration divestiture language and instead requires plans to offer in-person pharmacies within 30 miles of a covered person's home where such pharmacies are available. The amendment also requires plans to permit any pharmacy willing to accept contract terms to participate in the network.
The amendment bans clawbacks and holdbacks of claims paid to a pharmacy except where a claim is fraudulent or an actual overpayment occurred. It also prevents PBMs from reimbursing non-owned pharmacies at a rate more restrictive than PBM-owned pharmacies and allows pharmacists to help patients find lower-cost alternatives without fear of penalty, sponsors said.
Amendment 28 includes a tiered minimum-reimbursement approach intended as a compromise to aid small independent pharmacies: pharmacies that hold a license to sell beer, wine and liquor would be guaranteed payments at the NADAC (National Average Drug Acquisition Cost) price as a minimum reimbursement; pharmacies without such a liquor license would be guaranteed NADAC plus the dispensing fee used by Medicaid, sponsors said. Several members raised concerns about the liquor-license test and whether it would unintentionally exclude small "mom and pop" pharmacies that hold a liquor license but do not rely on liquor sales for margin.
Representative Shackleford described the clause as a compromise aimed at ensuring at least some additional payment to smaller independents while sponsors said they ultimately prefer a dispensing fee for everyone but were negotiating toward a measure members would accept.
The amendment also prevents a third-party administrator (TPA) from compelling a plan sponsor to use the TPA's own vertically integrated PBM and says a plan sponsor's choice not to use a vertically integrated PBM should be premium neutral.
The committee discussed definitions and implementation questions several times and sponsors said they will continue to refine the language. On a roll call the committee approved the amended bill 13-0.
The committee adjourned after thanking legislative staff for drafting assistance.
