2022 Drug Pricing Update: States Continue Legislative Push Even As Congress Passes Long Sought Changes
Alert
71 min read
States remain at the forefront of legislative efforts on a range of issues relating to drug pricing, such as increasing price transparency, capping out-of-pocket costs for insulin, and limiting certain PBM practices. These state-level efforts continue as Congress makes headlines with legislation allowing Medicare to "negotiate" prices with manufacturers on a narrow group of drugs.
Since our last update, states have continued to maintain a steady pace of action on prescription drug cost issues, collectively passing more than 30 new laws while proposing hundreds more. As revealed by our state-by-state chart below, this activity generally reflects trends observed over the past few years, with much of the state-level effort focused on issues such as increasing the transparency of drug prices, ensuring that the benefits of manufacturer co-pay assistance offers reach consumers, capping consumer out-of-pocket cost for insulin, reducing discriminatory contracting against 340B providers or their contract pharmacies, and eliminating certain types of PBM practices, such as spread pricing.
For example, on price transparency, Vermont led the way in 2016 by requiring annual disclosure of up to 15 prescription drugs on which the state spends significant health care dollars and of those drugs whose list price has increased by 50% or more over the past five years or by 15% or more over the past 12 months.1 Today, more than a dozen states have passed similar, and in some instances broader, price transparency laws.2 A new law in Illinois requires pharmacists to provide consumers with the price of any brand or generic prescription drug.3 Similarly, recent legislation in Virginia requires PBMs to provide formulary data to covered consumers and healthcare providers for prescription drugs, including any cost-sharing requirements or prior authorization requirements.4
Also, states increasingly have sought to impact drug prices by regulating PBMs and their practices. Notably, New York recently passed legislation requiring PBMs to register with and obtain licensing from the State Department of Financial Services, potentially setting the stage for further regulation.5 Failure to comply with these requirements may result in the PBM receiving cease and desist orders as well as incurring financial penalties.6 The new legislation likewise imposes additional duties and obligations on PBMs, such as providing a process to appeal, investigate, and ultimately resolve disputes raised by pharmacies regarding multi-source generic drug reimbursements.7 Other laws, such as Virginia's S.B 426, require managed care organizations to include in their contracts with PBMs provisions prohibiting so-called spread pricing, whereby the PBM pays the pharmacy less for the prescription drug than it charges health plans with the PBM retaining the difference.8
Consumer out-of-pocket costs for insulin also continue to be an issue, with numerous states adopting caps on consumer co-payments for their monthly supply. Spearheaded by Colorado in 2019, more than 16 states now have such caps in place.9
These continued state efforts come alongside the recent enactment of the federal Inflation Reduction Act, which implements a range of Democratic priorities on drug pricing.10 Most notable are the Medicare price negotiation provisions, which allow the Department of Health and Human Service to use the threat of an excise task to "negotiate" Medicare Part B and D prices with drug manufacturers for a small set of high-expenditure drugs and biologics. Manufacturers already have signaled their intention to challenge this part of the Act.11 The Act also requires manufacturers to pay mandatory rebates on certain Medicare Parts B and D drugs and biologics with price increases that exceed the rate of inflation. An additional provision adjusts Medicare Part B add-on payment for biosimilars in certain instances. For Part D consumers, the Act lowers the out-of-pocket limit to $2,000, eliminates deductibles for insulin and adult vaccines, and caps insulin co-pays at $35 per month. To help pay for its spending, the Act postpones implementation of Trump-era amendments to safe harbor regulations that implicate the federal anti-kickback law until January 1, 2032.
Insights and Takeaways:
In addition to the recent developments at the federal level, states continued their push for drug pricing reform since our last update. Below are several key takeaways:
- Evolving landscape of state laws presents increased compliance risks. States continue to heighten compliance burdens for drug makers, PBMs, and other participants in the distribution and payment chain. Industry actors should continue to monitor the growingly complex web of state (and federal) laws affecting them in order to manage compliance, minimize risks and government scrutiny, and avoid fines and penalties.
- PBM practices are not only being regulated but also curtailed by new state laws. At both the state and federal levels, PBMs are now seen as exerting enormous influence over the prices paid for prescription drugs. States have expanded beyond transparency and other regulatory efforts to target certain PBM practices, such as spread pricing. These efforts come amidst ramped up FTC interest, including the launch in June 2022 of a deep dive study into the PBM industry that merits monitoring.12
- Continued focus on consumer out-of-pocket costs when filling prescriptions. States continue to take steps to address concerns regarding the cost burdens faced by insured consumers when filling prescriptions. These efforts, which range from drug specific actions, like capping consumer cost sharing on insulin, to more general ones, such as prohibitions on co-pay accumulators, seem likely to increase absent broader changes at the federal level.
White & Case's Pharmaceutical & Healthcare Group continues to identify, track, and evaluate state legislation concerning drug pricing and provides up to date information on a state-by-state basis in the chart below.
Drug Pricing Tracker - State Laws
(last updated September 2022)
| State | Legislative Target(s) | Category | Act Title | Summary of Law* | Link to Law |
| e.g., Pharmacy Benefit Managers (PBMs), Pharmaceutical Company, Pharmaceutical Manufacturers, Pharmacists, Insurers, Canadian Drug Importation | e.g., Drug Price, Transparency, Drug Affordability Review, Study, Coupons/Cost Sharing, Licensing, Substitution | *These summaries do not cover every provision contained in the laws listed below. Each bill should be consulted for its full text. | |||
| Alabama | PBMs | Licensing, Drug Price, Transparency | SB 73: Alabama Pharmacy Benefit Manager Licensure and Regulation Act | Requires PBMs to register with the Department of Insurance and be licensed by January 1, 2020 to conduct business in the state. Prohibits PBMs from preventing pharmacies and pharmacists from disclosing the amount an individual would pay for a drug without insurance. PBMs may not require a plan member to pay more than either the contracted co-payment amount or the cash retail value, whichever is less. | Link |
| Alabama | PBMs | Drug Price, Transparency | SB 227/HB 492: An Act Relating to Healthcare | Prohibits PBMs from engaging in certain activities, including preventing a pharmacist from sharing cost information with consumers; charging a pharmacy a point-of-sale or retroactive fee or otherwise recouping funds from a pharmacy in connection with claims for which the pharmacy has already been paid; or reimbursing pharmacies less than similarly situated PBM affiliates. This measure requires PBMs to be licensed and to prepare an annual report that discloses aggregate rebate information and whether the PBM engages in, if requested by a health insurer client. | Link |
| Alabama | Insurers | Coupons/Cost Sharing | HB 249: Health Benefit Plans, Insulin Prescription Drugs, Co-pay Limited | Requires a health benefit plan to cap the total amount that a beneficiary with diabetes must pay for a 30-day supply of a covered prescription insulin drug at $100, regardless of the amount or type of insulin needed to fill the prescription. | Link |
| Arizona | PBMs, Insurers | Coupons (restricts copay accumulators) | HB 2166: An Act Relating to Insurance Cost Sharing | Requires PBMs and Insurers to include in any cost sharing requirement, the amount paid by either the enrollee or another person on behalf of the enrollee (e.g., through a coupon) for drugs (1) without a generic equivalent or (2) where the enrollee has authorization to use drug instead of the generic equivalent. | Link |
| Arizona | PBMs | Transparency | HB 2285: An Act amending Section 20-3321, Arizona Revised Statutes | Requires PBMs, among other things, to update their maximum allowable cost (MAC) lists in a timely manner, to share with pharmacies the sources used to determine MAC pricing, and to establish an appeal process by which pharmacies can appeal MAC pricing reimbursement. It further bars PBMs from, among other things, prohibiting retail pharmacies from dispensing 90 prescription refills if certain conditions are met, or prohibiting retail pharmacies from offering mail delivery of drugs as an ancillary service. | Link |
| Arizona | PBMs | Other | SB 1356: Prohibition Against Claim Adjudication Process Fees; Civil Remedies | Prohibits a PBM from directly or indirectly, on behalf of a plan sponsor or insurer, charging or holding a pharmacist or pharmacy responsible for a fee for any step of or component or mechanism related to the claims adjudication process. | Link |
| Arkansas | Pharmacists | Substitution (biosimilars) | HB 1269: An Act to allow Pharmacists to Make Biological Product Substitutions; And for Other Purposes | Allows pharmacists to substitute an interchangeable biosimilar product under specified circumstances when the substitution would result in cost savings to the patient. Notice to the prescriber of the substitution within five business days is required if requested. | Link |
| Arkansas | PBMs | 340B-covered Facilities | HB 1881: An Act to Establish the 340B Drug Pricing Nondiscrimination Act; And For Other Purposes | Prohibits PBMs and health plans from discriminating against 340B-covered entities and their contract pharmacies. The bill also prohibits drug manufacturers from discriminating against 340B contract pharmacies by denying access to the manufacturer's drugs or by denying the pharmacy access to 340B pricing. | Link |
| Arkansas | PBMs | Transparency, Drug Price, PBM Spread Pricing | SB 520: An Act to clarify the State Insurance Department's Regulatory and Enforcement Authority Concerning Pharmacy Benefit Managers; to Modify Arkansas Pharmacy Benefit Manager Licensure Act; and For Other Purposes | Amends the required appeal process for pharmacies to challenge plan reimbursements. Directs PBMs to reimburse pharmacies at rates no less than specified benchmarks and limits retroactive and certain other adjustments to pharmacy claims. Prohibits spread pricing by PBMs. Requires PBMs to report certain rebate and other information to the Insurance Commissioner quarterly. | Link |
| Arkansas | Insurers | Cost-sharing | HB 1569: An Act to Establish the Arkansas Fairness in Cost Sharing Act | Ensures that a state-regulated insurer and the entities that contract with the state-regulated insurer do not restrict patient access to prescription drugs by refusing to count third-party cost-sharing assistance toward a patient's cost-sharing obligations. | Link |
| Arkansas | Pharmaceutical Manufacturers | Coupons/Cost- Sharing | SB 7/HB 1005: An Act to Repeal the Law Concerning Pharmaceutical Discounts for Insulin; to Declare an Emergency; and for Other Purposes | Repeals existing law concerning pharmaceutical discounts for insulin. Finds that pharmaceutical manufacturer discounts may negatively impact the economy of the state, leading to higher costs on health benefit plans. | Link |
| Arkansas | PBMs, Pharmaceutical Manufacturers | Coupons | HB 1709: An Act to Provide Guidelines on How Rebates are Offered by a Pharmaceutical Manufacturer that Sells Insulin in this State | Defines pharmaceutical manufacturer discounts. Prohibits a pharmaceutical manufacturer or any of its affiliates from providing discounts on any insulin products unless the discount is provided directly to the end user in the form of a discount coupon card and it is adjudicated in real time. | Link |
| California | Pharmaceutical Manufacturers, Insurers | Drug Price, Transparency | SB 17: An Act Relating to Health Care | Imposes several new disclosure requirements, including requiring Insurers to provide annual reports on the 25 most frequently prescribed drugs, the 25 most costly drugs, and the 25 drugs with the highest year-over-year increases in price. It further requires drug manufacturers to provide notice if they intend to introduce a new prescription drug at a cost that exceeds the threshold set out in Medicare Part D to be designated a "specialty drug" under federal law. | Link |
| California | Pharmaceutical Manufacturers | Patent Settlement | AB 824: An Act to add Division 114.01 to the Health and Safety Code, relating to Business | On October 7, 2019, California became the first state to enact legislation—Assembly Bill 824—rendering certain pharmaceutical patent litigation settlement agreements presumptively anticompetitive. | Link; see also Link (White & Case's antitrust team outline of potential effects of this law). |
| California | Pharmaceutical Manufacturers | Cost Regulation | SB 852: An Act to Add Chapter 10 (commencing with Section 127690) to Part 2 of Division 107 of, and to Repeal Sections 127694 and 127695 of, the Health and Safety Code, Relating to Health Care | Requires the California Health and Human Services Agency (CHHSA) to enter into partnerships to produce or distribute generic prescription drugs and at least one form of insulin. CHHSA required to submit a report to the Legislature on or before July 1, 2023, that assesses the feasibility and advantages of directly manufacturing targeted generic drugs. | Link |
| Colorado | PBMs | Transparency | HB 20-1078: Pharmacy Benefit Management Firm Claims Payment | Prohibits PBMs from retroactively reducing payment on a clean claim submitted by a pharmacy. The measure also prohibits a PBM from reimbursing a pharmacy in an amount less than the amount the PBM reimburses any affiliate for the same pharmacy services. | Link |
| Colorado | Canadian Drug Importation | Transparency | SB 19-005: Dr. Irene Aguilar Canadian Prescription Drug Importation Act | Creates a program to allow the importation of prescription drugs from Canada to Colorado, subject to regulatory oversight and approval from the federal government. | Link |
| Colorado | Pharmaceutical Manufacturers | Drug Price, Transparency | HB 19-1131: An Act Concerning a Requirement to Share the Wholesale Acquisition Cost of a Drug When Sharing Information Concerning the Drug with Another Party | Requires pharmaceutical manufacturers who market to prescribers to disclose a drug's wholesale acquisition cost as well as the names of up to three generic drugs in the therapeutic class, should they exist. | Link |
| Colorado | Insurers | Cost Regulation, Drug Price | HB 19-1216: An Act concerning Measures to Reduce a Patient's Cost of Prescription Drugs, and in connection, therewith, making an Appropriation | Requires Insurers to cap the cost of insulin for covered plan members at no more than $100 per 30-day supply, regardless of the amount of insulin a patient needs. The Act also requires the Department of Law to investigate insulin prices and present its findings in a report no later than November 1, 2020. | Link |
| Colorado | PBMs | Drug Price | HB 21-1237: An Act Concerning The Creation of a Competitive Pharmacy Benefits Manager Marketplace | Requires the State Employees Group Benefit plan to use a reverse auction to contract with a PBM in its selection of PBM, sets criteria for payment reconciliation and market checks on PBM performance, and creates a pathway for self-funded health plan participation in future reverse auctions. | Link |
| Colorado | Canadian and other nations importing drugs | Importation | SB 21-123: An Act Concerning Expanding the Canadian Prescription Drug Importation Program to Include Prescription Drug Suppliers from Nations other than Canada upon the Enactment of Legislation by the United States Congress Authorizing Such Practice | Expands the Canadian drug prescription importation program to include drug suppliers from other nations if certain conditions are met. | Link |
| Colorado | Colorado prescription drug affordability review board (board) in the division of insurance (division) | Drug Price, Transparency | SB 21-175: An Act Concerning the Colorado Prescription Drug Affordability Review Board | Requires that the Prescription Drug Affordability Review Board perform affordability reviews of prescription drugs, and authorizes the Board to establish upper payment limits for prescription drugs that the Board determines are unaffordable for Colorado consumers. | Link |
| Colorado | Pharmacies | Coupons/Cost-Sharing | HB 21-1307: An Act Concerning Measures to Increase Access to Prescription Insulin for Persons with Diabetes | Requires a health coverage plan to cap the total amount that a carrier can require from a covered patient to pay for a 30-day supply of all covered insulin drugs at $100, regardless of the amount or type of insulin needed to fill the prescription. For eligible individuals, pharmacists must provide access to one emergency prescription insulin supply within a 12-month period at a cost not to exceed $35 for a 30-day supply. | Link |
| Colorado | PBMs, 340B | Drug Price, Cost Regulation | HB 22-1122: An Act Concerning Prohibiting Certain Practices by Entities Obligated to Pay For Prescription Drug Benefits | Prohibits PBMs from reimbursing pharmacies for a prescription drug in an amount less than the National Average Drug Acquisition Cost for the prescription drug and from discriminating against 340B-covered entities. | Link |
| Colorado | PBMs, Insurers | Transparency, Drug Price | HB 22-1370: An Act Concerning Coverage Requirements for Health-Care Products | Requires health insurance carriers that offer an individual or small group health benefit plan to offer at least 25% of its health benefit plans on the Colorado health benefit exchange and at least 25% of its plans not on the exchange in each benefit level and in each service area as copayment-only payment structures for all prescription drug cost tiers. Prohibits PBMs from modifying the current prescription drug formulary during the current plan year. PBMs must also demonstrate that 100% of received rebates for dispensing or administering prescription drugs are used to reduce costs, whether to reduce employer and individual costs or to reduce consumers' premiums and out-of-pocket costs for prescription drugs. | Link |
| Connecticut | Insurers | Cost-Sharing | HB 6622: An Act Concerning Prescription Drug Formularies and Lists of Covered Drugs | Limits the circumstances in which a health carrier may remove a prescription drug from a drug formulary or list of covered drugs, or move a prescription drug to a different cost-sharing tier, during a plan year. | Link |
| Connecticut | PBMs, Insurers | Coupons/Cost- Sharing | HB 1003: An Act Prohibiting Certain Health Carriers and Pharmacy Benefits Mangers from Employing Copay Accumulator Programs | Requires certain health carriers and pharmacy benefits managers to give credit for payments made by third parties for the amount of, or any portion of the amount of, an insured's or enrollee's cost-sharing liability for a covered benefit. | Link |
| Delaware | PBMs, Insurers | Drug Price | HB 24: An Act to amend Title 18 of the Delaware Code relating to Copayment or Coinsurance for Prescription Drugs | Prohibits Insurers and PBMs from imposing a copayment or coinsurance requirement for a prescription drug that exceeds the price of that prescription drug, the contract price for the drug, or the copayment that would exist notwithstanding this law, whichever is less. | Link |
| Delaware | PBMs | Transparency, Drug Price | HB 194: An Act to amend Title 18 of the Delaware Code Relating to Pharmacy Benefits Managers | Along with other reporting requirements, this Act requires that PBMs utilize an appeal process for pharmacies to challenge plan reimbursements. | Link |
| Delaware | Insurers | Coupons/Cost Sharing | HB 263: An Act to Amend Title 18 and Title 29 of the Delaware Code Relation to Cost Sharing in Prescription Insulin Drugs | Requires that individual, group, and state employee insurance plans cap the amount an individual must pay for insulin prescriptions at $100 a month and must include at least one formulation of insulin on the lowest tier of the drug formulary developed and maintained by the plan. | Link |
| Delaware | PBMs | Transparency | HB: 219: An Act to Amend Title 18 of the Delaware Code Relating to Pharmacy Benefits Managers | Provides enhanced oversight and transparency as it relates to PBMs. Allows a pharmacy to decline to dispense a prescription drug to a patient if the amount reimbursed by a PBM is less than the pharmacy acquisition cost. Requires PBMs to provide reports to the Insurance Commissioner on the amounts of rebates received and distributed. Prohibits PBMs from spread pricing and reimbursing a pharmacy in an amount less than the PBM reimburses itself or an affiliate for the same drug or service. | Link |
| Delaware | Insurers; PBMs | Drug Price | SB 250: Coverage Requirements For Health-Care Products | For prescription drugs with a copayment, the copayment amount for the highest drug cost tier must not be greater than 1/12th of the health benefit plan's out-of-pocket maximum amount. No more than 50% of the drugs on the prescription drug formulary used to treat a specific condition may be placed on the highest prescription drug cost tier. Each health benefit plan issued or renewed after January 1, 2021 shall use 100% of discounts received from a manufacturer in connection with dispensing or administering prescriptions drugs to reduce costs. Likewise, 100% of rebates received in connection with dispensing or administering prescription drugs must be used to reduce policyholder costs. | Link |
| Florida | Pharmaceutical Manufacturers, Canadian Drug Importation | Importation | HB19: Canadian Prescription Drug Importation Program | Creates the program to allow the importation of prescription drugs from Canada to Florida, subject to regulatory oversight and approval from the federal government. | Link |
| Florida | Pharmaceutical Manufacturers, Agency for Persons with Disabilities, Canadian Drug Importation | Importation | SB 2526: An Act Relating to Health | Authorizes pharmacists and wholesalers employed by or under contract with forensic facilities managed by the Agency for Persons with Disabilities to import prescription drugs from eligible Canadian suppliers for clients in such facilities. | Link |
| Georgia | Pharmacists | Other; Patient Data Privacy | HB 233: Pharmacy Anti-Steering and Transparency Act | Prohibits pharmacies from sharing patient or prescriber identifying data for any commercial purpose outside the scope of serving patients. | Link |
| Georgia | PBMs | Transparency | HB 323: An Act Relating to Regulation and Licensure of Pharmacy Benefit Managers | Requires PBMs to report annually the total amount of rebates received from pharmaceutical manufacturers that the PBM did not pass on to its clients. | Link |
| Georgia | PBMs | Drug Price | HB 946/SB 313: Insurance; Extensive Revisions Regarding Pharmacy Benefits Managers | Revises regulation of PBMs to (1) require PBMs to use CMS's national average drug acquisition cost (NADAC) as a point of reference for the ingredient cost component of pharmacy reimbursement for drugs appearing on the NADAC list; (2) prohibit PBMs from engaging in any practice that includes imposing a point-of-sale fee or retroactive fee, or deriving any revenue from a pharmacy or enrollee in connection with performing PBM services; (3) require PBMs to offer 100% pass through of manufacturer rebates to health plans; (4) require PBMs to offer a health plan the option of charging the health plan the same price for a prescription drug as it pays a pharmacy for the drug (to eliminate spread pricing), unless the PBM is contracted with the state, in which case the PBM will be required to charge a plan the same price for a drug as it pays a pharmacy; (5) requires PBMs to report certain manufacturer rebate information and certain spread pricing information to health plans; and (6) requires PBMs to include copay and other consumer cost sharing assistance towards the consumers out of pocket maximum deductible or copayment responsibility. | Link |
| Georgia | Department of Community Health | Transparency | HB 1276: Relating to the Department of Community Health | Requires the Department of Community Health to publish biannually on the department website data on prescription drug spending. This data shall include aggregate payment amounts for the ten most frequently prescribed, and ten most costly medications; data related to the volume and cost of such medications; and costs of net rebates. | Link |
| Hawaii | No Recently Enacted Legislation Applicable | ||||
| Idaho | PBMs | Legislation, Drug Price | HB 386: An Act relating to Pharmacy Benefit Managers | Adds to existing law regulating PBM activities to: prohibit PBMs from limiting pharmacist's ability to provide cost sharing information or clinical efficacy of more affordable alternatives to consumers, provide certain requirements for MAC pricing and appeals, and prohibit the retroactive denial or reduction of a claim in certain instances. | Link |
| Illinois | PBMs | Drug Price, Transparency | HB 465: An Act concerning Regulation | Provides that a contract between a health insurer and a PBM must: (1) require the PBM to update maximum allowable cost pricing information and maintain a process that will eliminate drugs from maximum allowable cost lists or modify drug prices to remain consistent with changes in pricing data; (2) prohibit PBMs from limiting a pharmacist's ability to disclose the availability of a more affordable alternative drug; and (3) prohibit PBMs from requiring an insured to make a payment for a prescription drug in an amount that exceeds the lesser of the applicable cost-sharing amount or the retail price of the drug. | Link |
| Illinois | Insurers | Drug Price | SB 667: An Act concerning Regulation | Among other details, this measure provides that insurers must limit the total amount an enrollee is required to pay for insulin to $100 per 30-day supply, regardless of the type and amount needed. It also directs the Department of Insurance to issue a report by November 1, 2020 regarding insulin pricing practices and recommendations to control and prevent overpricing of insulin. | Link |
| Illinois | Pharmacies | Transparency | SB 1682: An Act concerning Regulation | Amends the Pharmacy Practice Act by removing the provision limiting consumers to ten requests of disclosures. Requires pharmacists to disclose the retail price of any brand or generic prescription drug or medical device to the consumer. If the consumer's cost-sharing amount exceeds the retail price, then the pharmacist must disclose it to the consumer. | Link |
| Illinois | PBMs | Cost-Sharing, 340B Entities | HB 4595: An Act concerning Regulation | Prohibits certain specified provisions in a contract between a PBM or a third-party payer and a 340B entity or a 340B pharmacy. Contracts entered into after July 1, 2022 containing such provisions shall be void and unenforceable. | Link |
| Indiana | PBMs, Insurers | Drug Price | HB 1207: An Act to Amend the Indiana Code Concerning Professions and Occupations | Provides that a state employee plan, a health maintenance organization, an insurer, or a PBM may not require a pharmacy or pharmacist to collect a higher copayment for a prescription drug from a covered individual than the health plan provider allows the pharmacy or pharmacist to retain. Requires an insurer to provide 60 days' notice to specified insured consumers and opportunity for appeal, when removing a prescription drug from the insurer's formulary or changing the applicable cost sharing requirements. | Link |
| Indiana | PBMs, Insurers | Licensing, Other | SB 241: An Act to Amend the Indiana Code Concerning Insurance | Prohibits PBMs from reducing pharmacy payments to an effective rate of reimbursement or from reimbursing PBM-affiliated pharmacies at a rate greater than other pharmacies in the PBM's network. Establishes guidelines for how PBMs can set MAC pricing and sets up an appeals process for pharmacies to dispute MAC rates. Requires PBMs to disclose upon request to their health plan customers that actual amounts paid by the PBM to any pharmacy. Creates licensing and reporting requirements for PBMs, including required reporting starting June 1, 2021 of certain rebate and administrative fee information. | Link |
| Iowa | PBMs | Transparency | SF 563: An Act Relating to PBMs and Information Related to the Management of Prescription Drug Benefits, and including Applicability Provisions | Requires each PBM to submit an annual report to the Insurance Commissioner that includes, among other things, aggregate rebate amounts and administrative fees received from prescription pharmaceutical manufacturers and the amount of those rebates and fees that were not passed through to the PBM's health plan clients. | Link |
| Iowa | PBMs | Drug Price, Cost-Sharing | HF 2384: An Act Relating to Pharmacy Benefits Managers, Pharmacies, and Prescription Drug Benefits. | PBMs may not prohibit a pharmacy from disclosing the availability of a lower-cost prescription drug option to a covered person, or from selling a lower-cost prescription drug option to a covered person. Lists the requirements PBMs must meet to place a particular prescription drug on a maximum allowable cost list. Prohibits a PBM from reimbursing any in-state pharmacy an amount less than the amount reimbursed to a PBM affiliate for dispensing the same prescription drug. | Link |
| Kansas | PBMs | Drug Prices, Restrictions on PBMs | SB 28: House Substitute for SB 28 by Committee on Insurance and Pensions – Enacting the Pharmacy Benefits Manager Licensure Act and Requiring Licensure Rather Than Registration of Such Entities | Provides that PBMs shall not place a drug on a maximum allowable cost (MAC) list, unless there are at least two therapeutically equivalent multi-source generic drugs, or at least one generic drug available from at least one manufacturer. PBMs shall disclose the sources utilized to determine the MAC price, and provide a process for each network pharmacy provider to readily access the maximum allowable price specific to that drug. Requires the establishment of a reasonable administrative appeal procedure to allow a pharmacy to challenge MAC for a specific drug. | Link |
| Kentucky | PBMs | Other | SB 50: An Act Relating to Pharmacy Benefits in the Medicaid Program and Declaring an Emergency | Requires the Department for Medicaid Services to contract with a PBM to be the state's PBM and for each managed care organization contracted for Managed Medicaid to use the state's PBM. For Managed Medicaid, the state's PBM is (1) required to use pass-through pricing as well as specified preferred drug lists and reimbursement methodologies; and (2) prohibited from using spread pricing or from reducing pharmacy payments to an effective reimbursement rate or imposing certain other pharmacy limits/restrictions. | Link |
| Kentucky | Insurers | Coupons/Cost- Sharing | HB 95: An Act Relating to Prescription Insulin | Amend KRS 304-17A.148 to cap the cost-sharing requirements for prescription insulin at $30 per 30-day supply. | Link |
| Kentucky | Insurers, PBMs | Coupons/Cost- Sharing | SB 45: An Act Relating to Prescription Drugs | Amends KRS 304.17A-164 to redefine "cost-sharing" and define "generic alternative." Prohibits an insurer or PBM from excluding any cost-sharing amount paid by or behalf of an insured when calculating the insured's contribution to any applicable cost-sharing requirement. | Link |
| Louisiana | Insurer, Pharmacists, PBMs | Drug Price, Transparency | HB 436: An Act Relative to Coverage of Prescription Drugs | Prohibits entities that administer prescription drug benefit programs in Louisiana from prohibiting a pharmacist from informing a patient of 'all relevant options" and their cost and efficacy. Also prohibits PBMs from reimbursing pharmacies less than the amount paid to the PBM's affiliates for the same service. | Link |
| Louisiana | PBMs | Licensing, Drug Price, Transparency | SB 41: An Act Relative to Regulation of PBMs | Large-scale reform of PBM requirements in Louisiana, which, among other things, requires PBM registration and regulation by certain state agencies and prohibits "spread pricing" without providing the required notice. | Link |
| Louisiana | Pharmacists, PBMs | Other | HB 433: An Act Relative to Business Practices of Pharmacists, Pharmacies, and PBMs | Provides new regulations governing the interactions between pharmacists and PBMs, including prohibiting PBMs from reimbursing its affiliates more than non-affiliated pharmacies and subjecting those who violate the law to actions and penalties provided for in the Unfair Trade Practices and Consumer Protection Law. | Link |
| Louisiana | PBMs | Licensing, Coupons | SB 239: An Act Relative to the Medicaid Prescription Drug Benefit Program | Among other things, this law authorizes the Louisiana Department of Health to remove pharmacy services from Medicaid managed care organization contracts and assume direct responsibility for such Medicaid pharmacy services. | Link |
| Louisiana | PBMs | Drug Price | SB 180: Provides Relative to State Procurement of Certain Services by Use of Reverse Auction Technology. | Authorizes the Department of Health and the Office of Group Benefits to procure and negotiate PBM contracts by using a reverse auction. | Link |
| Louisiana | Insurers, PBMs | Coupons/Cost- Sharing | SB 94: An Act Relative to Insurance Cost-Sharing Practices | Amends and Reenact R.S. 22:1641(8) and enacts R.S. 22:976.1. Requires health insurance issuer to include any cost-sharing amounts paid by the enrollee or on behalf of the enrollee by another person when calculating an enrollee's contribution to any applicable cost-sharing requirement. | Link |
| Louisiana | Insurers, PBMs, Pharmacists | Cost-Sharing | SB 191: An Act to Enact Subpart A-3 of Part III of Chapter 4 of Title 22 of the Louisiana Revised Statutes 3 of 1950, comprised of R.S. 22:1020.51 through 1020.53, Relative to Provider-Administered Drugs. | Prohibits a covered person to pay an additional fee, or any other increased cost-sharing amount in addition to applicable cost-sharing amounts payable by the covered person as designated within the benefit plan to obtain the physician-administered drug when provided by a participating provider. | Link |
| Louisiana | Insurers | Cost-Sharing | HB 677: Provides Relative to Cost Sharing for Insulin Prescriptions | Caps the total amount that a carrier can require an enrollee to pay for a 30-day supply of insulin at $75, regardless of the amount or type of insulin needed to fill the prescription. On January first of each year, this amount may be increased by a percentage equal to the percentage change from the preceding year in the prescription drug component of the US Consumer Price Index. | Link |
| Maine | Insurers, Pharmacists, PBMs | Drug Price, Transparency | LD 6: An Act to Prohibit Insurance Carriers from Charging Enrollees for Prescription Drugs in Amounts that Exceed the Drugs' Costs | Prohibits Insurers or PBMs from requiring a copayment or other charge that exceeds the claim cost of a drug. It further prohibits Insurers or PBMs from penalizing pharmacists for disclosing costs or efficacy information to patients. | Link |
| Maine | Pharmaceutical Manufactures | Coupons/Cost-Sharing | LD 673: An Act to Create the Insulin Safety Net Program | Creates the Insulin Safety Net Program, where a pharmacy will dispense a 30-day supply of insulin to eligible individuals at a cost of no more than $35 for a 30-day supply. Prohibits a pharmacy from seeking reimbursement from insulin received through the Insulin Safety Net Program or third-party payor. The pharmacy may collect a copayment from the individual to cover the pharmacy's costs for processing and dispensing in an amount not to exceed $50 for a 90-day supply if the insulin is sent to the pharmacy. | Link |
| Maine | PBMs, Pharmaceutical Manufacturers | Transparency | LD 686: An Act to Increase Prescription Drug Pricing Transparency | Revises the Maine Health Data Organization's authority to request and publish a list of the prescription drugs for which the manufacturer has: (1) increased the wholesale acquisition cost (WAC) of a brand-name drug by more than 20% per pricing unit; (2) increased the WAC of a generic drug that costs at least $10 per pricing unit more than 20% per pricing unit; or (3) introduced a new drug with a WAC that exceeds the threshold for a specialty drug under the Medicare Part D Program (currently $670). The law also revises the process for disclosures by manufacturers, wholesale drug distributors and PBMs and updates the confidentiality provisions applicable to information provided. | Link |
| Maine | Pharmaceutical Manufacturers | Drug Price, Transparency | LD 1162: An Act to Further Expand Drug Price; Transparency | Manufacturers must provide annual drug price reports to the Maine Health Data Organization. The annual reports must notify the Organization if the manufacturer has (1) increased the wholesale acquisition cost of a brand name or generic drug by more than 20%; or (2) introduced a new drug for distribution that has a cost greater than the threshold for being designated a "specialty drug" under Medicare Part D. If the Organization requests information relating to a specific prescription drug, the manufacturer must provide the Organization with the price per unit within 60 days. Failure to comply can result in monetary fines. Effective January 30, 2020. Requires the Maine Health Data Organization to publish an annual report on the information from the Manufacturer reports, with various privacy protections. Effective November 1, 2020. | Link |
| Maine | Pharmaceutical Manufacturers | Importation | LD 1272: An Act to Increase Access to Low-cost Prescription Drugs | Provides for the Department of Health and Human Services to adopt rules to work to establish a program to import Canadian drugs. By May 1, 2020, the Department will submit a request for approval of the drug importation program to the Federal Department of Health and Human Services. Effective January 1, 2020. | Link |
| Maine | N/A | Drug Affordability Review | LD 1499: An Act to Establish the Maine Prescription Drug Affordability Board | Establishes the Maine Prescription Drug Affordability Review Board, which is authorized to determine spending targets on certain specific drugs that may cause affordability challenges to enrollees in a public payor health plan and provide a number or other broad powers including the ability to establish a common formulary for all public payers, enter into bulk purchasing agreements, and negotiate certain rebate amounts. | Link |
| Maine | Pharmaceutical Manufacturers | Drug Price, Transparency | LD 1406: An Act to Promote Prescription Drug Price; Transparency | Empowers the Maine Health Data Organization to develop a plan to collect data from manufacturers related to the pricing of drugs. | Link |
| Maine | PBMs | Licensing, Other | LD 1504: An Act to Protect Consumers from Unfair Practices Related to Pharmacy Benefits Management | Prohibits "spread pricing" by PBMs absent notice to the State. Requires PBMs to have a license to operate in the state and to apply a single maximum allowable cost list. Effective January 1, 2020. | Link |
| Maine | Canadian Drug Importation, Pharmaceutical Manufacturers | Drug Affordability Review | LD 1636: An Act to Determine Potential Savings in Prescription Drug Costs by Using International Pricing | Authorizes the insurance commissioner to identify the 100 most costly prescription drugs and the 100 most frequently prescribed prescription drugs to determine the referenced rate by comparing the wholesale acquisition cost (WAC) to reference costs based on prices in Canada's four largest provinces. The lowest price in those provinces will become the legal upper payment limit for those drugs for participating purchasers in the state. | Link |
| Maine | Insurer, PBMs | Coupons/Cost Sharing | LD 1783: An Act to Require Health Insurance Carriers and Pharmacy Benefits Managers to Appropriately Account for Cost-sharing Amounts Paid on Behalf of Insureds | Requires health insurance carriers and their PBMs to include cost-sharing amounts paid on behalf of an insured when calculating the insured's contribution to any out-of-pocket maximum, deductible, or copayment when a drug does not have a generic equivalent or was obtained through prior authorization, a step therapy override exception or an exception or appeal process. | Link |
| Maine | Insurers | Other | LD 1928: An Act to prohibit Health Insurance Carriers from Retroactively Reducing Payment on Clean Claims Submitted by Pharmacies | Prohibits insurers (or their intermediaries) from charging a pharmacy or holding a pharmacy responsible for any fee related to a clean claim that is not apparent at the time the claim is processed, that is not reported on the remittance advice, or that is applied after the initial claim is adjudicated. | Link |
| Maine | Insurers | Drug Price | LD 2096: An Act to save Lives by Capping the Out-of-pocket Cost of Certain Medications | Restricts insurers providing prescription insulin drug coverage from imposing any deductible or other cost-sharing requirement that results in out-of-pocket costs that exceed $35 per prescription for a 30-day supply, regardless of the amount of insulin needed to fill the enrollee's insulin prescriptions. | Link |
| Maryland | PBMs | Other | HB 973: An Act Concerning Pharmacy Services Administrative Organizations and Pharmacy Benefits Managers – Contracts | Requires PBMs) to disclose to a pharmacy, at the time of entering a contract and at least 30 days before any contract change: the applicable terms and reimbursement rates, processes and procedures for verifying pharmacy benefits and eligibility, dispute resolution and audit appeals processes, and the process and procedures for verifying the prescription drugs included on the PBM's formularies. The measure prohibits a pharmacy services administrative organization that has not registered with the Commissioner from entering into an agreement or contract with a PBM or an independent pharmacy. | Link |
| Maryland | PBMs | Transparency | HB 1150: State Health and Welfare Benefits Program – Maryland Competitive Pharmacy Benefits Manager Marketplace Act | Authorizes the Department of Budget and Management to procure and negotiate PBM contracts by using a reverse auction and sets forth certain parameters related to that process. | Link |
| Maryland | PBMs | Drug Price, Other | HB 1274: An Act Concerning Prescription Drugs – Pharmacy Benefits Managers – Federal 340B Program | Prohibits PBMs from discriminating against a pharmacy or pharmacist engaged in the federal 340B program or against beneficiaries involved in, or receiving a prescription drug from a pharmacy involved in the 340B program. A PBM may not prohibit a beneficiary from choosing his or her own pharmacy; transfer 340B savings from a pharmacy or pharmacist to a PBM; offer lower reimbursement for or refuse to cover a prescription drug purchased under the 340B program; or refuse to allow pharmacies that participate in the 340B program to participate in the PBM's network. | Link |
| Maryland | PBMs | Transparency | HB 1307: Credentialing and Reimbursement | Creates certain limits on PBMs' pharmacy credentialing requirements and prohibits PBMs from charging a fee for initial credentialing or renewal. Also prohibits PBMs from reducing pharmacy reimbursement under a reconciliation process. | Link |
| Maryland | Insurer, PBMs | Drug Price | HB 1397: An Act Concerning Health Insurance – Prescription Insulin Drugs – Limits on Copayment and Coinsurance | Requires insurers to cap a covered insulin drug at $30 per 30-day supply, regardless of the amount or type of insulin needed. Insurers, nonprofit health service plans, and health maintenance organizations providing coverage for prescription drugs are prohibited from imposing a copayment or coinsurance requirement on a prescription drug prescribed to treat diabetes, HIV, or AIDS that exceeds $150 for up to a 30-day supply of the drug. | Link |
| Maryland | Pharmacy Services Administrative Organizations | Other | SB 915: Pharmacy Services Administrative Organizations- Regulation | Increases regulation of pharmacy services administrative organizations, including requiring registration with Maryland Insurance Commission and creating filing disclosure obligations. | Link |
| Maryland | Pharmaceutical Manufacturers | Drug Price | HB 631: An Act concerning Public Health – Essential Off-Patent of Generic Drugs – Price Gouging – Prohibition | This price gouging law would have prevented manufacturers from implementing "unconscionable" price increases on certain drugs. In 2018, a Federal appellate court held the law is unconstitutional because it regulated commerce outside of Maryland's borders. Leave to appeal to the Supreme Court of the United States was denied in February 2019. | Link |
| Massachusetts | Pharmaceutical Manufacturers | Drug Affordability Review, Transparency | H 4000: An Act Making Appropriations for the Fiscal Year 2020 for the Maintenance of the Departments, Boards, Commissions, Institutions and Certain Activities of the Commonwealth, for Interest, Sinking Fund and Serial Bond Requirements And for Certain Permanent Improvements | Among other provisions, this law requires certain pharmaceutical manufacturers to disclose certain information regarding drug prices, price increases, and research and development spending to the Executive Office of Health and Human Services. Based on the submitted information, the Executive Office of Health of Human Services may identify and negotiate supplemental rebates for drugs with total annual costs exceeding certain thresholds. If a supplemental pricing rebate is not agreed on, the Manufacturer may be subject to further disclosure requirements. | Link |
| Michigan | PBMs | Drug Price, Other | SB 139: Appropriations; Health and Human Services; Department of Health and Human Services (provide for fiscal year 2019-2020) | Starting February 1, 2020 this law prohibits the Department of Health and Human Services from entering into contracts with Medicaid managed care organizations that use PBMs that fail to utilize certain reimbursement methodologies and fail to agree to move transparent pass-through pricing. | Link |
| Michigan | PBMs | Licensing, Transparency, Drug Pricing | HB 4348: An Act to License and Regulate Pharmacy Benefit Managers | Prohibits PBMs from engaging in spread pricing and requires them to submit annual transparency reports detailing aggregate rebate information. | Link |
| Michigan | Insurer, PBMs | Other | HB 4351: An Act to Provide for, and Regulate Certain Actions by a Carrier Relating to Prescription Drugs | Prohibits insurers and PBMs from discriminating against 340B-covered entities. Insurer and PBMs cannot prohibit pharmacies from disclosing the current selling price of a drug in a contract. | Link |
| Michigan | PBMs | Transparency, Other | HB 4352: An Act to Amend 1978 PA 368; An Act to Protect and Promote the Public Health | Requires pharmacists to provide the current selling price of a drug dispensed by that pharmacy or comparative current selling prices of generic and brand name drugs or biosimilar drug products and must display a notice stating that consumers have the right to find out the price of a prescription drug before filling the prescription. Prohibits a pharmacy from entering into a contract with a PBM that interferes in any manner with a patient's choice to receive a prescription drug from a 340B entity. | Link |
| Michigan | Insurers | Transparency | SB 447: Insurance: Health Insurers; Disclosure of Group Health Claim Utilization | Requires insurers to provide large employer groups with claims utilization and cost information for prescription drugs, upon request of the large employer group and presentation of a signed NDA. | Link |
| Minnesota | PBMs | Transparency | HF 2128: Omnibus Health and Human Services Policy and Finance Bill | Prohibits PBMs and health plans from imposing contract terms that prevent pharmacists from sharing with insured consumers the pharmacy's acquisition cost for a drug, the amount the pharmacy is being reimbursed by the PBM. Also prevents PBM contract terms that prevent pharmacies from discussing with health plans the reimbursement amount paid by a PBM or the pharmacy's acquisition cost. | Link |
| Minnesota | Other | Transparency, Drug Pricing | SF 1098: Prescription Transparency Drug Pricing Act | Requires drug manufacturers to submit specified pricing information to the commissioner of health for certain new drugs and for existing drugs with price increases above a defined threshold. The commissioner is directed to post on its website (subject to certain confidentiality restrictions) the reported pricing information. Failure to comply with the reporting requirements may subject a manufacturer to civil penalties not to exceed $10,000 per day of violation. | Link |
| Minnesota | PBMs | Licensing, Substitution | SF 278: An Act Relating to Health Care | Requires PBMs to be licensed to operate in the State; to report information regarding aggregate pharmaceutical manufacturer rebates, retained rebates, spread pricing, and other information to the Commissioner of Commerce; and to provide pharmacies certain information regarding the development of maximum allowable cost lists. This bill also permits pharmacists, with respect to a prescription not covered by the consumer's prescription drug plan, to dispense a therapeutically equivalent and interchangeable prescribed drug that is covered, pursuant to certain conditions and requirements. | Link |
| Minnesota | Insurers | Drug Price | SB 12: Omnibus Health and Human Services Appropriation Bill | Appropriations bill with a number of detailed limitations, such as limiting cost sharing on insulin and regulating the sale of medical cannabis. | Link |
| Minnesota | Pharmaceutical Manufacturers | Drug Price | HF3100: Alec Smith Insulin Affordability Act | Obligates pharmaceutical manufacturers to make insulin available to eligible individuals, who urgently need insulin or require access to an affordable insulin supply. | Link |
| Mississippi | No Recently Enacted Legislation Applicable | ||||
| Missouri | No Recently Enacted Legislation Applicable | ||||
| Montana | PBMs | Transparency, Drug Price | SB 395: Montana Pharmacy Benefit Manager Oversight Act | Establishes the standards and criteria for licensure and regulation of PBMs. The bill also (1) prohibits PBMs from including clauses in contracts with pharmacies that prevent the disclosure of the process that is used to authorize or deny drug coverage or benefits; (2) requires PBMs to disclose to health plans certain cost information, including wholesale acquisition costs from a manufacturer and aggregate rebate amounts from manufacturers; and (3) prevents PBMs from excluding 340B entities or their contract pharmacies from networks or reimbursing them differently than similarly situated pharmacies. | Link |
| Montana | PBMs, Insurers | Transparency, Drug Price | SB 270: An Act Revising Conditions for a Network Pharmacy or Pharmacist | Imposes a prospective requirement that regulated entities (e.g., PBMs) provide pharmacies with their maximum allowable price list at the time of contracting and prohibits regulated entities from penalizing pharmacies for sharing reimbursement information with patients. | Link |
| Nebraska | PBMs, Insurers | Drug Price, Transparency | LB 316: A Bill for an Act Relating to Pharmacy; to Adopt the Pharmacy Benefit Fairness Act | Prohibits regulated entities (e.g., Insurers) from requiring a point-of-sale payment in excess of either the non-insured cash cost or the patient's contractual payment, whichever is less. Further prohibits penalizing pharmacies for disclosing cost related information to patients. | Link |
| Nebraska | PBMS | Licensing, Transparency, Cost-sharing | LB 767: An Act Relating to Pharmacy Benefit Managers | Establishes standards and criteria for the licensure and regulation of PBMs and prohibits the use of gag clauses by PBMs in their contracts with pharmacies. PBMs may not require a covered individual to pay more than their cost-sharing amount under the terms of a health benefit plan. Requires PBMs to reimburse 340B entities at the same rate as non-340B entities, and prevents PBMs from interfering with a patient's choice to receive a prescription drug from their pharmacy of choice, including a 340B entity. | Link |
| Nevada | PBMs | Drug Price, Transparency | AB 141: An Act Relating to Pharmacy Benefit Managers | Prohibits a PBM from preventing a pharmacy from disclosing less expensive options to patients and from penalizing a pharmacy for selling a less expensive generic drug to patients. | Link |
| Nevada | Pharmaceutical Manufacturers | Drug Price, Transparency | SB 262: An Act Relating to Prescription Drugs | Extends certain reporting requirements for the sale of diabetes treating drugs to treatments for asthma. | Link |
| Nevada | PBMs | Transparency, Drug Price | SB 378: An Act Relating to Prescription Drugs | This law alters a number of existing provisions related to PBMs, including altering the standard governing a PBM's contractual relationship from a fiduciary standard to a good-faith standard. It further alters how the state operates its Medicaid program by allowing the Department of Health and Human Services to contract with a PBM for the administration of the State Plan for Medicaid and the Children's Health Insurance Program. | Link |
| Nevada | PBMs, Pharmaceutical Manufacturers | Transparency | SB 380: Revises Provisions Governing the Reporting of Data Concerning the Prices of Prescription Drugs | Revises the Department of Health and Human Services' responsibility for reporting information on drug prices by adding drugs with a WAC exceeding $40 for a course of therapy that have been subject to an increase in WAC of 10% or greater during the immediately preceding calendar year or 20% or greater during the immediately preceding two calendar years and removing asthma drugs. Manufacturer reporting responsibilities are expanded to cover this new category of drugs. The bill also updates the reporting requirements for PBMs and adds a new reporting requirement for wholesalers that sell prescription drugs included on either or both of the lists compiled by the state. | Link |
| Nevada | Pharmaceutical Manufacturers | Drug Price | SB 396: An Act Relating to Prescription Drugs | Authorizes the Department of Health and Human Services to enter into a contract with one or more public or private entities from the District of Columbia and other states for the collaborative purchasing of prescription drugs. | Link |
| Nevada | Pharmacists, PBMs, Pharmaceutical Manufacturers | Drug Price, Transparency | SB 539: An Act Relating to Prescription Drugs | Creates a number of new reporting requirements related to the sale of drugs treating diabetes. | Link |
| New Hampshire | Pharmaceutical Manufacturers | Transparency | HB 703: Relative to Providing Notice of the Introduction of New High-cost Prescription Drugs | Creates a notice requirement for a new prescription drug introduced at a wholesale acquisition cost that exceeds the threshold set for a specialty drug under the Medicare Part D program. For such drugs, the manufacturer must provide notice to the Insurance Department and certain disclosures, including a description of the marketing and pricing plan for the drug in the US and internationally; the estimate volume of potential patients; whether the drug was granted breakthrough designation or priority review by FDA; and the date and price of acquisition if the drug was not developed by the manufacturer. Failure to provide the required disclosures may result in a civil penalty of not more than $1,000 per day, injunctive relief, and payment of attorneys' fees. | Link |
| New Hampshire | Pharmaceutical Manufacturers | Drug Price | HB 1280: Relative to Copayments for Insulin, Establishing a Wholesale Prescription Drug Importation Program, Establishing a New Hampshire Prescription Drug Affordability Board, Establishing the Prescription Drug Competitive Marketplace, Relative to the Pricing of Generic Prescription Drugs, Relative to Prior Authorization for Prescription Drug Coverage, and Requiring Insurance Coverage for Epinephrine Auto-Injectors. | The bill covers a number of topics, including: (1) requires health plans to cap insulin out of pocket cost at no more than $30 for 30-day supply; (2) establishes a wholesale importation program for prescription drugs from Canada by or on behalf of the state; (3) establishes a prescription drug affordability board to determine annual public payer spending targets for prescription drugs, develop and implement policies and procedures for the collection of prescription drug price data, implement a register of drug manufacturers for drug pricing data, and establish funding for the board by reasonable user fees and assessments; (4) revises the consumer protection law to include as an unfair method of competition or unfair and deceptive act or practice the pricing of generic prescription drugs in a manner that tends to create or maintain a monopoly or otherwise harm competition; (5) revises the managed care law to regulate the procedure for the prior authorization of drugs on a health plan formulary; (6) requires insurance coverage for epinephrine autoinjectors; and (7) adopts a reverse auction process for state health plan selection of PBMs. | Link |
| New Hampshire | PBMs | Drug Price | SB 226: An Act Relative to Registration of PBMs, and Reestablishing the Commission to Study Greater Transparency in Pharmaceutical Costs and Drug Rebate Programs | Creates a number of requirements for PBMs, including that PBMs must register to operate within the state and provide a process for pharmacies to appeal disputes regarding maximum allowable cost pricing. | Link |
| New Jersey | PBMs | Transparency | S 249: An Act Concerning Pharmacy Benefits Managers Providing Services Within the Medicaid Program | Requires PBMs providing services within Medicaid to disclose all sources and amounts of income, payments, financial benefits received, and costs and dispensing fees to the Department of Human Services. | Link |
| New Jersey | Other | Drug Pricing | S887: Requires DHS to Contract with Third Party Entity to Apply Risk Reduction Model to Medicaid Prescription Drug Services. | Requires the Department Human Services to transition Medicaid prescription drug services from a managed care delivery system to a fee-for-service delivery system and to conduct a reverse auction to contract with a PBM to administer the fee-for-service system. | Link |
| New Jersey | Pharmaceutical Manufacturers | Transparency | S 2389: An Act Concerning the Disclosure of Prescription Drug Price Information | Requires the Board of Pharmacy to establish a prescription drug pricing disclosure website and requires pharmaceutical manufacturers in the state to provide the current wholesale acquisition price for drugs or biologics marketed in the state. | Link |
| New Jersey | PBMs, Insurers | Drug Price | SB 2690: An Act Concerning Pharmacy Benefits Managers | Prohibits regulated entities (e.g., PBMs) from requiring a point-of-sale payment in excess of either the non-insured cash cost or the patient's contractual payment, whichever is less, and prohibits penalizing pharmacies for disclosing cost-related information to patients. | Link |
| New Mexico | Canadian Drug Importation | Drug Price | SB1: An Act Relating to Health; Enacting the Wholesale Prescription Drug Importation Act; Providing Power and Duties; Creating a Program; Creating a Committee; Requiring Federal Certification; Creating a Fund; Declaring an Emergency | This measure requires the Department of Health to design a wholesale prescription drug importation program that complies with federal requirements. | Link |
| New Mexico | Pharmaceutical Manufacturers, PBMs, Pharmacists | Drug Price | SB 131: An Act Relating to Procurement | This law established the "Interagency Pharmaceuticals Purchasing Council" to study, review, and coordinate ways to manage drug costs through group purchasing and other means. | Link |
| New Mexico | PBMs | Drug Price, Transparency, Volume Purchasing | SB 415: An Act Relating to Health Care | Creates a number of requirements for PBMs, including that PBMs must be licensed to operate within the state and provide a process for pharmacies to appeal disputes regarding maximum allowable cost pricing. | Link |
| New Mexico | Insurers | Drug Price | HB 292: Prescription Drug Cost Sharing | Requires insurers to cap the total amount an insured individual is required to pay for prescription insulin drugs at $25 per 30-day supply, regardless of the amount, or the number of prescription drugs or types of insulin prescribed. It also requires the superintendent of insurance to study the cost of prescription drugs for New Mexico consumers and make recommendations on increasing accessibility of prescription drugs in a report to be issued no later than October 1, 2020. | Link |
| New York | N/A | Transparency | SB 7506B: A Budget Bill | Directs the Department of Health to remove Medicaid pharmacy benefits from the managed care benefit package and provide those pharmacy benefits under the fee for service program to ensure transparency and efficiency of services. It also empowers the Superintendent of Insurance to investigate certain prescription drug price increases of more than 50% over a 12-month period and provide such information to the newly created drug accountability board, which is authorized in certain instances to evaluate and report to the Superintendent on (among other things) a drug's impact on premium costs, affordability, and price compared to therapeutic benefit. It also caps cost sharing for prescription insulin at $100 for a 30-day supply regardless of the amount of insulin needed to fill the prescription. | Link |
| New York | PBMs | Drug Price, Transparency | SB 1507: An Act to Amend the Public Health Law, in relation to Extending and Enhancing the Medicaid Drug Cap and to Reduce Unnecessary Pharmacy Benefit Manager Costs to the Medicare Program | Prohibits PBMs in the Medicaid program from retaining any portion of spread pricing and requires the registration of PBMs. | Link |
| New York | PBMs | Licensing, Drug Price Transparency | SB 3762: An Act to Amend the Public Health Law, in Relation to Pharmacy Benefit Managers | Requires PBMs (1) to annually report to the health plan any pricing discounts or rebates, (2) submit rebate information to the Superintendent of Insurance, (3) provide an appeals process for pharmacies regarding reimbursement for multi-source generic drugs, and (4) obtain a license before practicing in the state. Moreover, PMBs may not prohibit or penalize a pharmacist from disclosing information regarding the cost of the prescription or collect from an individual a copayment that exceeds the total submitted charges by the pharmacy. | Link |
| New York | PBMs | Transparency, Cost-Sharing | A8838/S7837: An Act to Amend the Public Health Law | Prohibits PBMs from using gag clauses in their contracts with pharmacies. | Link |
| North Carolina | PBMs | Licensing, Cost Sharing | SB 257: An Act to Promote Pricing Transparency for Patients and to Establish Standards and Criteria for the Regulation and Licensure of Pharmacy Benefits Managers Providing Services for Health Benefit Plans in North Carolina | Requires PBMs to obtain a license to operate; prohibits PBMs from including dispensing fees in the calculation of maximum allowable cost price; prevents PBMs from including gag clauses in their contracts with pharmacies; requires PBMs to establish an administrative appeals procedure by which a contract pharmacy may appeal the provider's reimbursement for any drug subject to maximum allowable cost pricing; requires any amount of a drug's cost paid on behalf of the enrollee to count toward the enrollee's annual out-of-pocket maximum or deductible; and prevents PBMs from discriminating against 340B-covered entities. | Link |
| North Carolina | Pharmacists, PBMs | Drug Price, Transparency | HB 466: An Act Relating to the Regulation of Pharmaceutical Benefit Managers | Imposes new requirements on the interactions between PBMs and pharmacists, including that (1) PBMs cannot prohibit pharmacists from providing cost share information to the patient or penalize a pharmacist for selling lower-priced drug to the patient if available, and (2) PBMs may not charge a co-payment greater than the total charge submitted by the pharmacy for the drug. | Link |
| North Dakota | Pharmaceutical Manufactures, PBMs, Insurers | Transparency | HB 1032: An Act to Create and Amend a New Chapter to Title 26.1 of the North Dakota Century Code, Relating to Prescription Drug Cost Transparency and to Wholesale Drug License Fees | Requires drug manufactures, PBMs and insurers to submit a report to the insurance commissioner regarding prescription drug cost transparency. | Link |
| North Dakota | PBMs | Transparency, Other | HB 1492: Permitting Pharmacists to Administer SARS-CoV-2 Tests; to Provide a Penalty; and to Declare an Emergency. | Prohibits health plans or their PBMs from disadvantaging 340B-covered entities or their contract pharmacies. | Link |
| Ohio | PBMs | Drug Price (Reimbursements) | SB 263: Prohibit Pharmacy Benefit Managers Acting on Certain Reimbursals. | Prohibits health plans or their PBMs from disadvantaging 340B-covered entities or their contract pharmacies in reimbursement rates or dispensing fees or through the imposition of other fees. | Link |
| Oklahoma | PBMs | Drug Price, Transparency | HB 2632: Patient's Right to Pharmacy Choice Act | Prohibits restrictions on a patient's right to choose a pharmacy provider without paying a penalty and creates an advisory committee to review complaints and administer fines. | Link |
| Oklahoma | Health Carriers | Drug Price, Cost Sharing | HB 1019: An Act Relating to Health Insurance; Amending 36 O.S. 2011, Section 6060.2, Which Relates to Treatment of Diabetes; Requiring Health Insurers to Cap Copayments for Insulin at a Certain Amount; Authorizing Insurers to Reduce Copayments Below Cap; Authorizing Insurance Commissioner to Enforce Cap on Copayments; Authorizing Insurance Commissioner to Promulgate Rules; and Providing an Effective Date | Caps the total amount that a carrier can require a covered patient with diabetes to pay for a 30-day supply of insulin at $30 and at $90 for a 90-day supply. | Link |
| Oklahoma | Insurers | Drug Price, Cost Sharing | SB 861: An Act Relating to Health Benefit Plans; Amending 36 O.S. 2021, Sections 6060.2 and 6060.4, Which Relate to Coverage for Diabetes Treatment and Child Immunization; Requiring Health Benefit Plans Provide Certain Coverage; Modifying Definition; and Providing an Effective Date | Caps the total amount that a carrier can require a covered patient with diabetes to pay for a 30-day supply of insulin at $30 and at $90 for a 90-day supply, regardless of amount or type of insulin prescribed. | Link |
| Oklahoma | PBMs, Pharmacies | Drug Price, Transparency | SB 737: An Act Relating to Pharmacy Benefits Management; Amending 36 O.S. 2021 | Prohibits (1) spread pricing, and (2) charging pharmacies a fee for joining retail pharmacy networks. Allows full disclosure of aggregate prescription drug discounts and rebates received from drug manufacturers. Requires quarterly reports to the commissioner on specific information regarding aggregate dollar amounts of rebates and administrative fees. | Link |
| Oregon | Pharmaceutical Manufacturers, Insurers | Drug Price, Transparency | HB 4005: An Act Relating to the Price of Prescription Drugs | Imposes a number of new reporting requirements on pharmaceutical manufacturers, including annual reports on certain factors regarding the manufacturer's price increases for drugs that cost $100 or more for a one-month supply and that increase in price by more than 10%. The law further requires that Insurers report information regarding their 25 most costly drugs. | Link |
| Oregon | Pharmaceutical Manufacturers | Drug Price, Transparency | HB 2658: An Act Relating to Prescription Drug Costs | Effective January 1, 2020, pharmaceutical manufacturers must report certain intended material price increases to Oregon's Department of Consumer and Business Services, including (1) the date of the increase, (2) the current price, (3) the amount of the increase, (4) an explanation of why the increase is necessary, and (5) the year the drug became available in the United States. | Link |
| Oregon | Pharmacy Benefits Managers | Drug Price, Transparency | HB 2185: An Act Relating to PBMs; Creating New Provisions; and Amending ORS 735.530 and 735.534 | Prohibits PBMs from requiring a prescription to be filled by a mail order pharmacy as a condition for reimbursing the cost of the drug. The law does, however, allow a PBM to require a prescription for a specialty drug to be filled at a specialty pharmacy as a condition for reimbursement of the cost of the drug. It further prohibits PBMs from restricting or penalizing network pharmacies for disclosing the difference between the out-of-pocket cost for the drug and the pharmacy's retail price for the drug. | Link |
| Oregon | Health Carriers | Drug Price, Cost Sharing | HB 2623: An Act Relating to the Cost of Insulin | Caps the total amount that a carrier can require a covered patient with diabetes to pay for a 30-day supply of insulin at $75 and at $225 for a 90-day supply. | Link |
| Pennsylvania | PBMs | Pharmacy Services and Study | HB 941: In Public Assistance, further providing for Medical Assistance Pharmacy Services and Providing for Prescription Drug Pricing Study | Amends regulation of the State's public assistance programs to prohibit an MCO or PBM from requiring an enrollee to use a specific pharmacy and a PBM from retaining a pharmacy spread, and instructs the Legislative Budget and Finance Committee to study prescription drug pricing under the medical assistance managed care program. | Link |
| Pennsylvania | PBMs and Pharmacists | Transparency | HB 943: Consumer Prescription Drug Pricing and Freedom Disclosure Act | Grants pharmacies the freedom to provide consumers drug cost and consumer cost sharing information, and prevents PBMs from prohibiting such disclosure or prohibiting pharmacies from disclosing the availability of therapeutically equivalent alternative drugs or selling more affordable alternatives to consumers. | Link |
| Rhode Island | PBMs and Pharmacists | Transparency | S 497: Prescription Drug Benefits | Plan sponsors, health insurers and PBMs cannot block pharmacists from providing cost sharing information to insured consumers and cannot penalize pharmacists for selling a lower-priced drug to an insured consumer. | Link |
| Rhode Island | Health Carriers | Drug Price, Cost Sharing | HB 5196: An Act Relating to Insurance – Prescription Drug Benefits | Caps the total amount that a carrier can require a covered patient with diabetes to pay for a 30-day supply of insulin at $40. | Link |
| South Carolina | PBMs | Licensing, Transparency | S 359: An Act to Amend the Code of Laws of South Carolina, 1976 | Establishes a State licensing requirement for PBMs and imposes a number of limitations on PBM operations. The law prevents PBMs from limiting the health care information pharmacists can provide to patients (i.e., information the pharmacists deem appropriate and within the scope of practice); prohibiting pharmacist from discussing certain cost information regarding drugs; or collecting a copay that exceeds the total contracted price, or the amount an individual would pay if that individual was paying cash, for the drugs, among other things. | Link |
| South Dakota | PBMs | Drug Price | HB 1137: An Act to Revise Certain Provisions Regarding Pharmacy Benefit Managers | Limits a PBM's ability to contract for certain terms, such as to charge a patient an amount that exceeds the amount retained by the pharmacist. | Link |
| Tennessee | PBMs | Drug Price | HB 786: An Act to Amend Tennessee Code Annotated, Title 56, Chapter 7, Part 31, Relative to Pharmacy Benefits Managers | Limits a PBM's ability to contract for certain terms, such as terms that would require a pharmacist to dispense a product contrary to the pharmacist's professional judgment, and prohibits PBMs from reimbursing pharmacies less than the amount reimbursed to the PBM's affiliate entities. | Link |
| Tennessee | PBMs | Drug Price and Transparency | SB 1617 / HB 1398: An Act to Amend Tennessee Code Annotated, Title 4; Title 56 and Title 71, Relative to Pharmacy Benefits. | Prohibits health plans and PBMs from taking certain steps, including the use of lower reimbursement rates, to discriminate against 340Bcovered entities or their contract pharmacies. | Link |
| Texas | Pharmaceutical Manufacturers, PBMs | Drug Price, Transparency | HB 2536: An Act Relating to Transparency Related to Drug Costs | Requires pharmaceutical manufacturers to provide reports of certain price increases for drugs which have a cost of at least $100 for a 30-day supply: Where the increase in price is greater than 40% or more over the previous three years, or greater than 15% over the last year, the manufacturer must provide a report within 30 days of the price change. | Link |
| Texas | Pharmaceutical Manufacturers | Drug Price, Transparency | SB 875 / HB 1033: An Act Relating to Prescription Drug Price Disclosure; Authorizing a Fee; Providing an Administrative Penalty | Requires manufacturers, along with their annual price transparency records, to disclose certain information related to prescription drugs in their annual report to the Department of State Health Services when a prescription drug with a wholesale acquisition cost of at least $100 for a 30-day supply increases in price by 40% or more over the preceding three calendar years or 15% or more in the preceding calendar year. Administrative penalties may be assessed against anyone who violates the requirement. | Link |
| Texas | Health Carriers | Drug Price, Cost Sharing | SB 827: An Act Relating to Health Benefit Plan Cost-Sharing Requirements for Prescription Insulin | Caps the total amount that a carrier can require a covered patient with diabetes to pay for a 30-day supply of insulin at $25. | Link |
| Utah | PBMs, Insurers, Pharmacists | Transparency | HB 370: Pharmacy Benefit Manager Amendments | Imposes a licensing and reporting requirement on PBMs and provides certain restrictions on claims reimbursements, as well as a prohibition on PBMs charging insured consumers costs sharing that exceeds the allowed claim amount, the total pharmacy reimbursement for the drug, or the retail price for the drug if not insured. | Link |
| Utah | Insurers | Coupons, Cost Sharing | HB 207: Insulin Access Amendments | With some exceptions, requires health benefit plans to cap the total amount that an insured is required to pay for insulin at an amount not to exceed $30 per 30-day supply, regardless of the amount of insulin needed and whether the insured has met her deductible. | Link |
| Utah | PBMs | Transparency, Cost Sharing | HB 272: Pharmacy Benefit Amendments | Amendments to the Pharmacy Benefit Act prevent PBMs from retroactively denying or reducing a pharmacy's claim and contracting with a health insurer in certain instances, unless the pharmacy benefit manager agrees to regularly report to the insurer detailed, claim-level information regarding pharmaceutical manufacturer rebates received by the PBM in connection with the contract. The Prescription Drug Price Transparency Act, among other things, requires manufactures to report certain information if the wholesale acquisition cost for a drug increases by 10% in one calendar year or 16% across two calendar years, including information regarding the factors that lead to the increase, recent FDA approvals, recent patent expirations, and certain R&D cost information. It also direct insurers to report certain information their 25 highest spend drugs. | Link |
| Utah | PBMs | Drug Price | SB 138: Pharmacy Benefit Revisions | Among other provisions, this measure prohibits PBMs from charging an enrollee, who uses an in-network retail pharmacy that offers delivery or mail order services, a fee or copayment that is higher than the fee or copayment the enrollee would pay if the enrollee used an in-network retail pharmacy that does not offer delivery or mail-order services. | Link |
| Utah | Manufacturers and Insurers | Transparency | HB 6011: Pharmaceutical Reporting Amendments | Defers implementation of manufacturer price reporting requirements to Jan. 1, 2022, and defers implementation of insurer reporting on prescription drug spending to Aug. 1, 2021. | Link |
| Vermont | Pharmaceutical Manufacturers | Drug Price, Transparency | SB 216: An Act Relating to Prescription Drugs | Authorizes the Vermont Attorney General to require manufacturers to provide justifications for price increases where the State spent "significant health care dollars" and where the wholesale acquisition cost of a drug has increased by a certain amount (by 50% over the last five years or by 15% over the last 12 months). | Link |
| Vermont | Pharmaceutical Manufacturers, Pharmacists, Insurers | Drug Price, Transparency, Substitution | S 92: An Act Relating to Prescription Drug Price; Transparency and Cost Containment | Imposes a number of requirements on different entities within the healthcare sector, including requiring pharmacists to select the lowest priced interchangeable biological product unless otherwise instructed by the prescriber (or the purchaser, if they agree to pay the extra cost). It further requires insurers to provide a report on the costs associated with covering prescription drugs and the year-over-year increases in drug prices. The law places varying reporting requirements on Insurers based upon the number of individuals they insure. | Link |
| Vermont | Pharmaceutical Manufacturers | Importation | S 175: An Act Relating to the Wholesale Importation of Prescription Drugs | Directs the Agency of Human Services to design a program for wholesale importation of prescription drugs from Canada in compliance with all applicable federal standards. | Link |
| Vermont | Pharmaceutical Company (Wholesalers) | Drug Price | H 542: An Act Relating to Making Appropriations for the Support of Government. | Directs the Agency of Human Services to extend the deadline by which the Agency of Human Services must implement a wholesale drug importation program. | Link |
| Vermont | PBMs, Insurers | Licensing, Transparency, Drug Price, Other | H 353: An Act Relating to Pharmacy Benefit Management | Requires PBMs to obtain licensure from the Department of Financial Regulation and to disclose certain information relating to prescription drugs. Requires the Department to monitor the cost impacts on Vermont consumers of PBM regulation and recommend appropriate modifications to the laws to promote health care affordability. PBMs cannot require a covered person purchasing a covered prescription drug to pay an amount greater than the dictated cost-sharing amount, or the maximum allowable cost for the drug, or the amount the covered person would pay for the drug if the covered person were paying the cash price or prohibit a pharmacy from discussing information regarding the drug's cost. | Link |
| Virginia | Insurers (third-party administrators) | Drug Price, Transparency | HB 29: A Budget Bill | Requires the Department of Human Resource Management to include language in all contracts with third-party administrators to maintain policies and procedures for transparency in pharmacy benefit administration programs. | Link |
| Virginia | Insurers | Drug Price | HB 66: An Act Relating to Health Insurance; Pharmacy Benefits; Cost-Sharing Payments for Prescription Insulin Drugs | Caps cost-sharing payments for prescription insulin drugs at $50 for 30-day supply of insulin. | Link |
| Virginia | PBMs | Transparency and Drug Price | HB 1290: Pharmacy Benefits Managers; Licensure and Regulation. (Incorporates HB 1292, HB 1459, HB 1479, HB 1659) | Requires PBMs to obtain a license from the State Corporation Commission and creates recordkeeping and reporting requirements for PBMs. The bill also prohibits PBMs from engaging in spread pricing, charging a pharmacist a fee related to the adjudication of a claim other than a reasonable fee for an initial claim submission, or reimbursing a pharmacy an amount less than the amount that the PBM reimburses an affiliate for providing the same services. | Link |
| Virginia | PBMs | Drug Price | HB 1291 / SB 568: Medical Assistance Services; Managed Care Organization Contracts with Pharmacy Benefits Managers. | This measure prohibits PBMs that contract with Medicaid managed care organizations from using spread pricing. The bill applies to agreements entered into, amended, extended, or renewed on or after July 1, 2020. | Link |
| Virginia | PBMs | Transparency | SB 251: Pharmacy Benefits Managers; Licensure and Regulation. (Incorporates SB 252 and SB 862) | Requires PBMs to obtain a license before operating in the state and prohibits PBMs from using false advertisement and from including any mail order pharmacy or PBM affiliate in calculating or determining network adequacy. The bill also requires PBMs to submit quarterly reports detailing manufacturer rebate information and prohibits PBMs from engaging in spread pricing. | Link |
| Virginia | PBMs | Drug Price, Cost Sharing | SB 568: An Act Relating to Medical Assistance Services; Managed Care Organization Contracts with Pharmacy Benefit Managers; Spread Pricing | Prohibits PBMs that contract with Medicaid managed care organizations from using spread pricing. | Link |
| Virginia | Insurers | Coupons, Drug Price | S 1596: An Act to Amend and Reenact §§ 38.2-4214 and 38.2-4319 of the Code of Virginia | Requires any insurance carrier in Virginia to count any payments made by another person on the enrollee's behalf, including payments through prescription drug coupons, toward a patient's out-of-pocket maximum cost sharing requirement for plans created or extended after January 1, 2020. | Link |
| Virginia | PBMs | Study and Drug Price | HJ 52: Requesting the Secretary of Health and Human Resources to Study the Establishment of a Prescription Drug Affordability Board. Report. | This measure urges the House of Delegates, the Senate, and the Secretary of Health and Human Resources to study the pharmaceutical distribution payment system in the state and innovative solutions to address the cost of prescription drugs to Virginians at the point of sale. The study must include a review of transparency for pharmaceutical manufacturers, PBMs, and health insurance carriers and develop and recommend a plan for the establishment of a Prescription Drug Affordability Board with the authority to review and regulate the cost of prescription drugs to be submitted to the legislature by September 14, 2021. | Link |
| Virginia | Health Carriers, PBMs, Distributors, Pharmaceutical Manufacturers | Transparency | HB 2007: An Act to Amend and Reenact § 2.2-3705.6 of the Code of Virginia. | Requires the Department of Health to contact with a nonprofit data services organization to annually collect, compile, and make available on its website publicly available information about prescription drug price increases. Requires health plans to submit the names of the 25 most frequently prescribed drugs, as well as the percent increase in annual net spending for prescription drugs after accounting for discounts. Requires wholesale distributors to report the maximum and minimum wholesale acquisition costs that they negotiated with the manufacturer, as well as aggregate total rebates and discounts and the total net income received in the last calendar year. Requires manufacturers to report cost information for each brand-name drug with a wholesale acquisition cost (WAC) of at least $100 that increased by 15% over one year, biosimilars that do not cost at least 15% less than the referenced biologic, or generics that cost at least $100 with a WAC increase of 200% in a year. Requires PBMs contracting with a carrier to offer the option of extending point-of-sale rebates to enrollees of the plan. | Link |
| Virginia | PBMs | Drug Price | HB 1162: An Act to Amend and Reenact §§38.2-3465 and 38.2-3467of the Code of Virginia, Relating to Health Insurance; Discrimination Prohibited Against Covered Entities and Contract Pharmacies | Prohibits carriers from (1) charging pharmacies fees for adjudicating claims other than a reasonable fee for an initial claim submission; (2) reimbursing pharmacies less than the amount the PBM reimburses an affiliate for providing the same services; (3) discriminating against a 340B-covered entity. | Link |
| Virginia | PBMs | Drug Price, Transparency | SB 426: An Act to Amend and Reenact §32.1-325 of the Code of Virginia, Relating to State Plan for Medical Assistance Services; Remote Patient Monitoring | Requires managed care organizations, in their contracts with PBMs, to include provisions prohibiting spread pricing by PBMs with regard to managed care plans. | Link |
| Virginia | PBMs, Health Carriers | Transparency | SB 428: An Act to Amend and Reenact §38.2-3407.15:2 of the Code of Virginia and to Amend the Code of Virginia by Adding a Section Numbered 38.2-3407.15:7, Relating to Health Insurance; Carrier Disclosure of Certain Information | Requires any PBM to provide real-time cost information data to enrollees and contracted providers for a prescription drug, including any cost-sharing requirement or prior authorization requirements. | Link |
| Virginia | PBMs | Cost-Sharing | HB 680: A Bill to amend and reenact §32.1-325 of the Code of Virginia, relating to state plan for medical assistance services; case management services; individuals with severe traumatic brain injury. | Requires MCOs with which the Department of Medical Assistance Services enters into agreements to include in any contract between the MCO and a PBM provisions prohibiting the PBM from engaging in spread pricing with regard to the MCO's managed care plans. | Link |
| Washington | Pharmaceutical Manufacturers, PBMs, Insurers | Drug Price, Transparency | HB 1224: An Act Relating to Prescription Drug Cost Transparency | Imposes a number of new reporting requirements on pharmaceutical manufacturers, PBMs, and Insurers related to price increases, prescription frequency, and reimbursement amounts. | Link |
| Washington | PBMs | Drug Price, Transparency | SB 5601: An Act Relating to Pharmacy Benefit Managers | Requires PBMs to obtain a license and prohibits PBMs from reimbursing a pharmacy or pharmacist in the state an amount less than the amount the PBM reimburses an affiliate for providing the same services. | Link |
| Washington | Pharmaceutical Companies, Insurers | Drug Price | HB 2662: An Act Reducing the Total Cost of Insulin | Creates the Total Cost of Insulin work group, which must submit a report to the governor and legislature detailing strategies to reduce the cost of and total expenditures on insulin for patients, carriers, and the state. This measure also requires health plans to cap cost-sharing for insulin at $100 per 30-day supply. | Link |
| Washington | Insurers | Drug Price | HB 6087: An Act Relating to Cost-Sharing Requirements for Coverage of Insulin Products | Caps the total amount than an insured individual is required to pay for insulin at $100 per 30-day supply and allows health plans to raise the cost-sharing amount for a 30-day supply by $5 for every $100 increase in the cost of an insulin product to the health plan. | Link |
| Washington | Pharmaceutical Manufacturers | Cost Regulation | SB 5203: An Act Relating to the Production, Distribution, and Purchase of Generic Prescription Drugs and Distribution or Purchase of Insulin; Amending RCW 70.14.060; and Adding a New Section to Chapter 70.14 RCW | Allows the Health Care Authority to enter into partnerships with other states or nonprofit orgs to produce, distribute, or purchase generic drugs and distribute and purchase insulin to achieve savings to public and private purchasers and consumers. State purchased health care programs would be required to purchase generics through the partnership, and local government and other entities will have the option to purchase generics from the authority as quantities allow. | Link |
| Washington | Pharmaceutical Manufacturers, PBMs, Insurers | Transparency, Drug Price | SB 5532: An Act Relating to Establishing a Prescription Drug Affordability Board; Amending RCW 43.71C.100 and 42.30.110; Adding a New Section to Chapter 48.43 RCW; Adding a New Chapter to Title 70 RCW; and Creating a New Section | Establishes the Prescription Drug Affordability Board and the Prescription Drug Affordability Stakeholder Council. The board must identify drugs that could create affordability challenges for the state or that trigger certain cost thresholds. The board will then determine whether to conduct an affordability review for the identified drugs. If the board conducts a review and determines a drug has led to or will lead to an affordability challenge, the board must establish an upper payment limit (UPL) for the drug. The board can set UPLs for up to 12 drugs each year. Any manufacturer that intends to withdraw a prescription drug from sale or distribution within the state because the board has established an upper payment limit for that drug shall provide a notice of withdrawal. The manufacturer that withdraws a drug from the market will be prohibited from selling that drug in the state for three years. | Link |
| Washington | Insurers | Drug Price, Cost Sharing | SB 5546: An Act Relating to Insulin Affordability; Amending RCW 41.05.017; Reenacting and Amending RCW 48.43.780; Providing an Effective Date; and Providing an Expiration Date | Caps the total amount that a carrier can require a covered patient with diabetes to pay for a 30-day supply of insulin at $35. | Link |
| West Virginia | PBMs, Insurers | Drug Price | HB 2770: A Bill to Amend the Code of West Virginia, 1931 | Effective January 1, 2020: When an insured's contributions to an applicable cost-sharing requirement is calculated (e.g., an out of pocket maximum), the Insurer and PBM must include the cost sharing amounts paid by the insured or on behalf of the insured by another person. | Link |
| West Virginia | Pharmaceutical Manufacturers, Insurers | Transparency | SB 689: An Act Relating to Enacting the Requiring Accountable Pharmaceutical Transparency, Oversight, and Reporting Act | Requires drug manufacturers to submit an annual report to the auditor with regard to brand and specialty drugs with a wholesale acquisition cost of at least $100 and an increase of 40% or more over the preceding three years or 15% of more in the previous year, including information regarding the factors that lead to the increases, recent patent expirations and certain R&D cost information. It also directs insurers to report certain information for their 25 most frequently prescribed drugs. | Link |
| West Virginia | PBMs | Transparency | SB 489: An Act Amending the Pharmacy Audit Integrity Act | Requires licensure of PBMs. | Link |
| West Virginia | PBMs, Insurers, Pharmaceutical Manufacturer | Drug Price | HB 4543: An Act Relating to Insurance Coverage for Diabetics | Caps the total amount that a carrier can required a covered patient with diabetes to pay for a 30-day supply of insulin at $100, regardless of the quantity or type of insulin needed to fill the person's needs. Also prohibits a manufacturer, wholesaler, or PBM from passing through the costs of the prescribed insulin to the pharmacist or pharmacy. | Link |
| West Virginia | PBMs | Drug Price and Transparency | HB 2263: Update the Regulation of Pharmacy Benefit Managers. | This bill (1) prohibits PBMs from collecting from a pharmacy a cost share charged to an enrollee that exceeds the total submitted charges by the pharmacist to the PBM;(2) prohibits PBMs from reimbursing a pharmacy or pharmacist an amount less than the national average drug acquisition cost (NADAC) at the time the drug is administered or dispensed, plus a dispensing fee; (3) requires PBMs to use NADAC as a point of reference for the ingredient drug product component of a pharmacy's reimbursement for drugs appearing on the NADAC list and to report on drugs reimbursed 10% below and above the NADAC; (4) requires PBMs to offer a health plan the option of charging the plan the same price for a prescription drug as it pays a pharmacy for the drug; directs PBMs to report to the health plan the difference between the amount the PBM reimbursed a pharmacy and the amount the PBM charged the health plan; and (5) mandates that an enrollee's cost sharing for each drug will be calculated at the point of sale based on a price that is reduced by an amount equal to at least 100% of all rebates received. Any rebate over and above the defined cost sharing will be passed on to the health plan to reduce premiums. | Link |
| West Virginia | Pharmaceutical Manufacturers | Transparency | SB 689: Requiring Accountable Pharmaceutical Transparency, Oversight, and Reporting Act. | This measure requires drug manufacturers and health plans to submit annual reports to the State Auditor. Manufacturer reports must cover generic, brand and specialty drugs that meet specified cost and price increase parameters, and include (among other things) information regarding WAC changes, aggregate company R&D costs, US revenues for drugs that lost patent exclusivity in the calendar year, and a statement regarding the factors that caused any WAC increase. Health benefit plan annual reports must cover certain aspects of prescription drug spending and their impact on premium. The bill requires the State Auditor to create a searchable pharmaceutical transparency website containing the information disclosed in the manufacturer and health plan annual reports. | Link |
| West Virginia | PBMs | Cost sharing, Licensing | HB 4112: An Act to Amend and Reenact §33-51-3, §33-51-8, §33-51-9, and §33-51-11 of the Code of West Virginia, 1931, as Amended; Provide Consumers a Choice for Pharmacy Services | Requires a PBM to be licensed with the Insurance Commissioner. Prohibits PBMs from discriminating against 340B entities, from reimbursing any pharmacy less than it reimburses a PBM-affiliated pharmacy for the same covered prescription drug, and from penalizing a pharmacist for sharing cost information with a consumer. | Link |
| Wisconsin | PBMs and Pharmacists | Transparency | SB 3: Pharmacy Benefit Managers, Prescription Drug Benefits, and Granting Rule-Making Authority. | Revises licensing and reporting requirements for PBMs and imposes certain limitation on activities of health plans and PBMs, including (1) limiting the situations in which pharmacy claims may denied retroactively; (2) prohibiting PBMs/plans from penalizing pharmacies for informing an enrollee of any differential between the out-of- pocket cost of a drug and the cost an individual would pay for the drug without using insurance; (3) prohibiting PBMs/plans from requiring an enrollee to pay more for a covered drug than either the enrollee's cost-sharing amount or the amount the enrollee would pay for the drug without using insurance, whichever amount is lower. Requires pharmacies to post a sign describing the pharmacy's ability to substitute a less expensive drug product equivalent or interchangeable biological product for the prescribed drug or biological product. Each pharmacy also must have available for the public (1) a listing of the retail price, updated monthly or more often, of the 100 most commonly prescribed prescription drugs available for purchase at the pharmacy, and (2) information describing how to access a list, created by the Pharmacy Examining Board, of the 100 most commonly prescribed generic drugs with the corresponding brand name, and the list of currently approved interchangeable biological products. | Link |
| Wyoming | PBMs | Transparency | HB 63: An Act Relating to Regulation of PBMs under the Insurance Code | Precludes PBMs from prohibiting or penalizing a pharmacy or pharmacist for informing a covered person about alternatives that may cost less than paying for a prescription drug using the person's prescription drug insurance. | Link |
1 Thomas Sullivan. "Vermont: First State to Pass Pharmaceutical Cost Transparency Bill." POLICY & MEDICINE (May 5, 2018), https://www.policymed.com/2016/05/vermont-first-state-to-pass-bill-on-pharmaceutical-cost-transparency.html.
2 These states include California, Connecticut, Georgia, Maine, Minnesota, Nevada, New Hampshire, North Carolina, North Dakota, Oregon, Texas, Vermont, Washington, and West Virginia.
3 An Act Concerning Regulation, Pub. Act 102-0400, Ill. SB 1682, 102nd Gen. Assemb. (2021), https://legiscan.com/IL/text/SB1682/2021.
4 An Act to Amend and Reenact, Va. SB 428, Gen. Assemb. (2022), https://lis.virginia.gov/cgi-bin/legp604.exe?221+ful+CHAP0285.
5 An Act to Amend the Public Health Law, N.Y. SB 3762, Gen. Assemb. (2021), https://assembly.state.ny.us/leg/default_fld=&bn=S03762&term=2021&Summary=Y&Actions=Y&Text=Y&Committee%26nbspVotes=Y&Floor%26nbspVotes=Y#S03762.
6 Id.
7 Id.
8 An Act to Amend and Reenact, Va. SB 426 (2022), https://lis.virginia.gov/cgi-bin/legp604.exe?221+ful+CHAP0269.
9 States with insulin cost sharing caps include: Alabama, Arkansas, Colorado, Connecticut, Delaware, Illinois, Kentucky, Maine, Minnesota, New Hampshire, New Mexico, New York, Oklahoma, Oregon, Texas, Utah, Virginia, Washington, and West Virginia.
10 Inflation Reduction Act of 2022, 168 Cong Rec S 4070.
11 Adam Lidgett & Jeff Overley, Big Pharma to Put Up Fight over Drug Price Negotiations, LAW360 (Aug. 12, 2022), https://www.law360.com/articles/1520819/big-pharma-expected-to-put-up-fight-over-drug-negotiations.
12 FTC Launches Inquiry Into Prescription Drug Middlemen Industry, FED. TRADE COMM’N (June 7, 2022), https://www.ftc.gov/news-events/news/press-releases/2022/06/ftc-launches-inquiry-prescription-drug-middlemen-industry.
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