Bill > HB2196

This bill, concerning pharmacy benefit managers (PBMs) and their reimbursement practices, aims to ensure that PBMs do not reimburse non-affiliated pharmacies for prescription drugs or devices at a rate lower than the pharmacy's actual acquisition cost. A PBM is an entity that administers prescription drug benefits on behalf of health insurers, Medicare Part D drug plans, or other payers. This bill prohibits PBMs from including professional dispensing fees in the calculation of reimbursement for drugs or devices, and mandates that they pay a professional dispensing fee at a rate no less than the fee-for-service methodology used in Arizona's state plan for medical assistance, which is the Arizona Health Care Cost Containment System (AHCCCS). Furthermore, PBMs must establish a clear appeals process within their contracts, allowing pharmacies to challenge reimbursement rates they believe are non-compliant. This appeals process must be filed within seven business days of reimbursement, and starting January 1, 2027, PBMs will need to submit their appeal procedures to the state for approval, with provisions allowing agents, such as pharmacy services administrative organizations, to file appeals on behalf of pharmacies. If a pharmacy successfully appeals a reimbursement rate, the PBM must adjust the reimbursement, provide the national drug code for the drug, allow the pharmacy to reverse and rebill the claim, reimburse the pharmacy's actual cost, and apply the corrected rate to other similarly situated pharmacies. If the PBM prevails in an appeal and the drug is available at a lower cost, they must provide the pharmacy with the name of a wholesaler and the drug's identifier. The bill also outlines consequences for PBMs that fail to comply with the reimbursement requirements, including adjusting the cost and allowing claim reversals. The director of the relevant department may establish a fee to administer this appeals process. Importantly, these provisions do not apply to health insurance coverage procured by the Department of Administration for state employees. The bill defines "nonaffiliated pharmacist or nonaffiliated pharmacy" as one not owned by or having an ownership interest in a PBM or its subsidiary, and "similarly situated pharmacists or pharmacies" as those under contract with a PBM who purchase the same drug or device and are subject to the same challenged reimbursement rate. These new regulations will apply to contracts entered into, amended, extended, or renewed on or after December 31, 2026.

Budget and Finance, Health and Social Services

https://apps.azleg.gov/BillStatus/BillOverview/83866