Bill > HB3538

This bill, effective November 1, 2026, aims to regulate Pharmacy Benefit Managers (PBMs), which are entities that manage prescription drug benefits for health plans. It introduces a new definition for "acquisition cost," which is the total amount a provider pays for a drug or medical product, evidenced by documentation like invoices, and excludes post-purchase rebates or discounts. The bill prohibits PBMs from refusing to accept additional documentation from providers during appeals regarding reimbursement amounts and requires PBMs to provide detailed claim-level information when making adjustments to provider reimbursements. Furthermore, it mandates that if a PBM approves a reimbursement appeal, they must make the adjusted reimbursement retroactive to the original date of service and, if the claim isn't reprocessed within 30 days, the PBM must pay the full required reimbursement, including retroactive adjustments, without requiring the provider to return any portion. The bill also establishes minimum reimbursement amounts, stating that PBMs cannot reimburse providers less than the national average drug acquisition cost plus a professional dispensing fee, or less than the wholesale acquisition cost if the national average is unavailable, with the dispensing fee to be evaluated and adjusted for inflation every two years.