Bill > HF852

Introduced Session

This bill relates to pharmacy benefits managers (PBMs), pharmacies, and prescription drugs. The bill prohibits a PBM from discriminating against a pharmacy or a pharmacist with regards to participation, referral, reimbursement of a covered service, or indemnification if a pharmacist acts within the scope of the pharmacist’s license and the pharmacy is operating in accordance with all applicable laws and rules. Under the bill, where a pharmacy or pharmacist has agreed to participate in a covered person’s (person’s) health benefit plan (plan), a PBM shall not prohibit or limit the person from selecting a pharmacy or pharmacist of their choice, or impose a monetary advantage or penalty as described in the bill. A PBM shall not deny a pharmacy or pharmacist the right to participate as a contract provider under a plan if the pharmacy or pharmacist agrees to the terms and requirements of the plan and the terms of reimbursement. A PBM shall not impose upon a pharmacy or pharmacist, as a condition of participation in a network, any course of study, accreditation, certification, or credentialing different than state requirements and rules of the board of pharmacy. A PBM shall not unreasonably designate a prescription drug (prescription) as a specialty drug to prevent a person from accessing the prescription or to limit a person’s access to the prescription from a pharmacy or pharmacist that is within the person’s plan’s network. A person or pharmacy harmed by such a violation may file a complaint. A PBM shall not require a person, as a condition of payment or reimbursement, to purchase pharmacy services exclusively through a mail order pharmacy. A PBM shall not impose upon a person any payment or condition to purchasing pharmacy services that is more costly or restrictive than if such services were purchased from a mail order pharmacy, or any other pharmacy. If a third-party payor providing reimbursement to persons for prescriptions restricts pharmacy participation, the third-party payor shall notify, in writing, all pharmacies within the geographical coverage area of the plan, and offer the opportunity to participate in the plan at least 60 days prior to the effective date of the restriction. All pharmacies in the geographical coverage area are eligible to participate under identical reimbursement terms. The third-party payor shall inform persons of the names and locations of all pharmacies participating in the plan. A participating pharmacy shall be entitled to announce the pharmacy’s participation to the pharmacy’s customers. The commissioner shall not certify any PBM or license an insurance producer not in compliance with the bill. A PBM shall not impose different cost-sharing or additional fees on a person based on the pharmacy at which the person fills a prescription order. A person’s cost-sharing for a prescription shall be calculated at the point of sale based on a price that is reduced by an amount equal to at least 100 percent of all rebates that have been received, or will be received, by the health carrier or a PBM in connection with the dispensing or administration of the prescription. A PBM shall include any amount paid by a person, or on behalf of a person, when calculating the person’s total contribution toward the person’s cost-sharing. Any amount paid by a person for a prescription shall be applied to any deductible imposed on the person by the person’s plan in accordance with the coverage documents. The bill prohibits a PBM from reimbursing a pharmacy in an amount less than the national average drug acquisition cost or the Iowa average acquisition cost or, if neither is available, the wholesale acquisition cost, for a prescription on the date that the prescription is administered or dispensed. A PBM also must reimburse the pharmacy or pharmacist a professional dispensing fee in an amount not less than the pharmacy dispensing fee published in the Iowa Medicaid enterprise provider fee schedule on the date that the prescription is administered or dispensed. The bill permits a pharmacy to decline to dispense a prescription to a person if the pharmacy will be reimbursed less for the prescription than the pharmacy’s acquisition cost. The bill requires all contracts executed, amended, adjusted, or renewed on or after July 1, 2025, that are applicable to prescription drug benefits on or after January 1, 2026, between a PBM and a third-party payor, or between a person and a third-party payor, to use a pass-through pricing model; to exclude terms that allow for spread pricing unless the entire amount of the difference caused by spread pricing is passed through by the PBM; and to ensure that payments received in relation to providing services to a third-party payor or a pharmacy are used or distributed pursuant to the PBM’s contract with the third-party payor or with the pharmacy, or as otherwise required. “Pass-through pricing” and “spread pricing” are defined in the bill. The bill requires a PBM to provide a process for pharmacies to appeal a reimbursement rate for a specific prescription. The appeal process is detailed in the bill. The bill applies to pharmacy benefits managers that manage a prescription drug benefit in the state on or after July 1, 2025.

No sponsors listed

Other Sponsors (1)

Withdrawn. H.J. 1140. (on 05/12/2025)

Official Document