Alabama 2025 Regular Session

Alabama Senate Bill SB93 Compare Versions

Only one version of the bill is available at this time.

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1	1	SB93INTRODUCED
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3	3	SB93
4	4	LUDQAAA-1
5	5	By Senators Jones, Butler, Beasley, Stewart, Chesteen, Kelley,
6	6	Barfoot, Allen, Price
7	7	RFD: Banking and Insurance
8	8	First Read: 04-Feb-25
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14	14	6 LUDQAAA-1 02/04/2025 JC (L)lg 2025-541
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16	16	First Read: 04-Feb-25
17	17	SYNOPSIS:
18	18	Pharmacy benefits managers are third-party
19	19	administrators of prescription drug benefits in a
20	20	health insurance plan. They are primarily responsible
21	21	for processing and paying prescription drug claims.
22	22	They typically negotiate price discounts and rebates
23	23	from manufacturers and determine how pharmacies get
24	24	reimbursed for dispensing prescriptions. Under state
25	25	law, pharmacy benefits managers are licensed and
26	26	regulated by the Department of Insurance.
27	27	This bill would prohibit pharmacy benefits
28	28	managers from reimbursing a pharmacy less than the
29	29	actual acquisition cost paid by the pharmacy and would
30	30	prohibit pharmacy benefits managers from charging
31	31	pharmacies or pharmacists miscellaneous fees related to
32	32	network participation and claims processing.
33	33	This bill would permit pharmacists to disclose
34	34	information to consumers about drug prices and
35	35	alternative drugs for treatment.
36	36	This bill would recognize the right of a
37	37	pharmacy to refuse to dispense a drug when the pharmacy
38	38	would be reimbursed less than a pharmacy's dispensing
39	39	cost, and would further prohibit a pharmacy benefits
40	40	manager from recovering the pharmacy's dispensing cost
41	41	by requiring a consumer to pay a higher deductible or
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71	71	by requiring a consumer to pay a higher deductible or
72	72	copayment.
73	73	This bill would specify that the Commissioner of
74	74	Insurance may enforce violations of the Alabama
75	75	Pharmacy Benefits Manager Licensure and Regulation Act
76	76	committed by a pharmacy benefits manager during an
77	77	audit of a pharmacy, and may also enforce the Pharmacy
78	78	Audit Integrity Act in relation to auditing of a
79	79	pharmacy by a pharmacy benefits manager.
80	80	A BILL
81	81	TO BE ENTITLED
82	82	AN ACT
83	83	Relating to pharmacy benefits managers; to amend
84	84	Sections 27-45A-3, 27-45A-6, 27-45A-7, 27-45A-8, and
85	85	27-45A-10, Code of Alabama 1975; to further regulate pharmacy
86	86	benefits managers in relation to pharmacies and pharmacists;
87	87	to further regulate reimbursement by pharmacy benefits
88	88	managers to pharmacies; to prohibit pharmacy benefits managers
89	89	from charging pharmacies certain fees; to permit pharmacists
90	90	to disclose drug information to covered individuals; to add
91	91	Section 27-45A-13 to the Code of Alabama 1975, to provide
92	92	circumstances when pharmacies may refuse to dispense drugs; to
93	93	amend Sections 34-23-181 and 34-23-185, Code of Alabama 1975,
94	94	to authorize the Commissioner of Insurance to enforce the
95	95	Pharmacy Audit Integrity Act; and to amend Section 34-23-187,
96	96	Code of Alabama 1975, to provide that an investigation into
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126	126	Code of Alabama 1975, to provide that an investigation into
127	127	fraud, waste, or abuse by a pharmacy benefits manager falls
128	128	under the Pharmacy Audit Integrity Act; and to add Section
129	129	34-23-188, to authorize the Commissioner of Insurance to
130	130	investigate complaints concerning an entity licensed by the
131	131	Department of Insurance that audits a pharmacy.
132	132	BE IT ENACTED BY THE LEGISLATURE OF ALABAMA:
133	133	Section 1. Sections 27-45A-3, 27-45A-6, 27-45A-7,
134	134	27-45A-8, and 27-45A-10, Code of Alabama 1975, are amended to
135	135	read as follows:
136	136	"§27-45A-3
137	137	For purposes of this chapter, the following words shall
138	138	have the following meanings:
139	139	(1) ACTUAL ACQUISITION COST. The Average Acquisition
140	140	Cost (AAC) of a drug for the State of Alabama, as published by
141	141	the Alabama Medicaid Agency. If no AAC is available, the term
142	142	means the wholesale acquisition cost (WAC + 0%).
143	143	(2) AFFILIATE or PBM AFFILIATE. An entity, including,
144	144	but not limited to, a pharmacy, health insurer, or group
145	145	purchasing organization that directly or indirectly, through
146	146	one or more intermediaries, has one of the following
147	147	affiliations:
148	148	a. Owns, controls, or has an investment interest in a
149	149	pharmacy benefits manager.
150	150	b. Is owned, controlled by, or has an investment
151	151	interest holder who is a pharmacy benefits manager.
152	152	c. Is under common ownership or corporate control with
153	153	a pharmacy benefits manager.
154	154	(1)(3) CLAIMS PROCESSING SERVICES. The administrative
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184	184	(1)(3) CLAIMS PROCESSING SERVICES. The administrative
185	185	services performed in connection with the processing and
186	186	adjudicating of claims relating to pharmacist services that
187	187	include any of the following:
188	188	a. Receiving payments for pharmacist services.
189	189	b. Making payments to pharmacists or pharmacies for
190	190	pharmacist services.
191	191	c. Both paragraphs a. and b.
192	192	(2)(4) COVERED INDIVIDUAL. A member, policyholder,
193	193	subscriber, enrollee, beneficiary, dependent, or other
194	194	individual participating in a health benefit plan.
195	195	(3)(5) HEALTH BENEFIT PLAN. A policy, contract,
196	196	certificate, or agreement entered into, offered, or issued by
197	197	a payor or health insurer to provide, deliver, arrange for,
198	198	pay for, or reimburse any of the costs of physical, mental, or
199	199	behavioral health care services , including pharmaceutical
200	200	services.
201	201	(4)(6) HEALTH INSURER. An entity subject to the
202	202	insurance laws of this state and rules of the department, or
203	203	subject to the jurisdiction of the department, that contracts
204	204	or offers to contract to provide, deliver, arrange for, pay
205	205	for, or reimburse any of the costs of health care services,
206	206	including, but not limited to, a sickness and accident
207	207	insurance company, a health maintenance organization operating
208	208	pursuant to Chapter 21A, a nonprofit hospital or health
209	209	service corporation, a health care service plan organized
210	210	pursuant to Article 6, Chapter 20 of Title 10A, or any other
211	211	entity providing a plan of health insurance, health benefits,
212	212	or health services.
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242	242	or health services.
243	243	(7) IN-NETWORK or NETWORK. A network of pharmacists or
244	244	pharmacies that are paid for pharmacist services pursuant to
245	245	an agreement with a health benefit plan or a pharmacy benefits
246	246	manager.
247	247	(5)(8) OTHER PRESCRIPTION DRUG OR DEVICE SERVICES.
248	248	Services, other than claims processing services, provided
249	249	directly or indirectly, whether in connection with or separate
250	250	from claims processing services, including, but not limited
251	251	to, any of the following:
252	252	a. Negotiating rebates , discounts, or other financial
253	253	incentives and arrangements with drug companies.
254	254	b. Disbursing or distributing rebates.
255	255	c. Managing or participating in incentive programs or
256	256	arrangements for pharmacist services.
257	257	d. Negotiating or entering into contractual
258	258	arrangements with pharmacists or pharmacies, or both.
259	259	e. Developing formularies.
260	260	f. Designing prescription benefit programs.
261	261	g. Advertising or promoting services.
262	262	(9) PAYOR. Any entity other than a health insurer
263	263	involved in the financing or payment of pharmacist services.
264	264	(6)(10) PHARMACIST. As defined in Section 34-23-1.
265	265	(7)(11) PHARMACIST SERVICES. Products, goods, and
266	266	services, or any combination of products, goods, and services,
267	267	provided as a part of the practice of pharmacy.
268	268	(8)(12) PHARMACY. As defined in Section 34-23-1.
269	269	(9)(13) PHARMACY BENEFITS MANAGER. a. A person,
270	270	including a wholly or partially owned or controlled subsidiary
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300	300	including a wholly or partially owned or controlled subsidiary
301	301	of a pharmacy benefits manager, that provides claims
302	302	processing services or other prescription drug or device
303	303	services, or both, to covered individuals who are employed in
304	304	or are residents of this state, for health benefit plans. The
305	305	term includes any person that administers a prescription
306	306	discount program directly for or on behalf of a pharmacy
307	307	benefits manager or health benefit plan for drugs to covered
308	308	individuals which are not reimbursed by a pharmacy benefits
309	309	manager or are not covered by a health benefit plan.
310	310	b. Pharmacy benefits manager does not include any of
311	311	the following:
312	312	1. A healthcarehealth care facility licensed in this
313	313	state.
314	314	2. A healthcarehealth care professional licensed in
315	315	this state.
316	316	3. A consultant who only provides advice as to the
317	317	selection or performance of a pharmacy benefits manager.
318	318	(10) PBM AFFILIATE. A pharmacy or pharmacist that,
319	319	directly or indirectly, through one or more intermediaries, is
320	320	owned or controlled by, or is under common control by, a
321	321	pharmacy benefits manager.
322	322	(11)(14) PRESCRIPTION DRUGS. Includes, but is not
323	323	limited to, certain infusion, compounded, and long-term care,
324	324	and specialty prescription drugs . The term does not include
325	325	specialty drugs.
326	326	(15) REBATE. Any payments or price concessions that
327	327	accrue to a pharmacy benefits manager or its health benefit
328	328	plan client, directly or indirectly, including through its PBM
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358	358	plan client, directly or indirectly, including through its PBM
359	359	affiliate or its subsidiary, third party, or intermediary,
360	360	including an off-shore purchasing organization, from a
361	361	pharmaceutical manufacturer or its affiliate, subsidiary,
362	362	third party, or intermediary. The term includes, but is not
363	363	limited to, payments, discounts, administration fees, credits,
364	364	incentives, or penalties associated, directly or indirectly,
365	365	in any way with claims administered on behalf of a health
366	366	benefit plan.
367	367	(12)(16) SPECIALTY DRUGS. Prescription medications that
368	368	require special handling, administration, or monitoring and
369	369	are used for the treatment of patients with serious health
370	370	conditions requiring complex therapies, and that are eligible
371	371	for specialty tier placement by the Centers for Medicare and
372	372	Medicaid Services pursuant to 42 C.F.R. § 423.560 .
373	373	(17) SPREAD PRICING. A prescription drug pricing model
374	374	used by a pharmacy benefits manager in which the pharmacy
375	375	benefits manager charges a health benefit plan a contracted
376	376	price for prescription drugs that differs from the amount the
377	377	pharmacy benefits manager pays the pharmacy for the
378	378	prescription drug, including any post-sale or
379	379	post-adjudication fees, discounts, or adjustments where not
380	380	prohibited by law ."
381	381	"§27-45A-6
382	382	(a) Nothing in this chapter is intended or shall be
383	383	construed to do any of the following:
384	384	(1) Bebe in conflict with existing relevant federal
385	385	law.
386	386	(2) Apply to any specialty drug.
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416	416	(2) Apply to any specialty drug.
417	417	(3) Impact or impact the ability of a hospital to
418	418	mandate its employees ' use of a hospital-owned pharmacy.
419	419	(b) The following provisions shall not apply to the
420	420	administration by a person of any term, including prescription
421	421	drug benefits, of a self-funded health benefit plan that is
422	422	governed by the federal Employee Retirement Income Security
423	423	Act of 1974, 29 U.S.C. §1001 et. seq.:
424	424	(1) Subdivisions (1) and (5) of Section 27-45A-8.
425	425	(2) Subdivisions (2), (3), (6), and (7) of Section
426	426	27-45A-10."
427	427	"§27-45A-7
428	428	ReservedIn addition to any other remedy provided by
429	429	law, a pharmacist, pharmacy, or covered individual who is
430	430	aggrieved by a violation of this chapter may bring a civil
431	431	action against a pharmacy benefits manager for damages or
432	432	equitable remedies ."
433	433	"§27-45A-8
434	434	With respect to a covered individual, Aa pharmacy
435	435	benefits manager , directly or through an affiliate or a
436	436	contracted third party, may not do any of the following:
437	437	(1) Require a covered individual, as a condition of
438	438	payment or reimbursement, to purchase pharmacist services,
439	439	including, but not limited to, prescription drugs, exclusively
440	440	through a mail-order pharmacy or pharmacy benefits manager
441	441	affiliate.
442	442	(2) Prohibit or limit any covered individual from
443	443	selecting an in-network pharmacy or pharmacist of his or her
444	444	choice who meets and agrees to the terms and conditions,
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474	474	choice who meets and agrees to the terms and conditions,
475	475	including reimbursements, in the pharmacy benefits manager's
476	476	contract.
477	477	(3) Impose a monetary advantage or penalty under a
478	478	health benefit plan that would affect a covered individual's
479	479	choice of pharmacy among those pharmacies that have chosen to
480	480	contract with the pharmacy benefits manager under the same
481	481	terms and conditions, including reimbursements. For purposes
482	482	of this subdivision, "monetary advantage or penalty" includes,
483	483	but is not limited to, a higher copayment, a waiver of a
484	484	copayment, a reduction in reimbursement services, a
485	485	requirement or limit on the number of days of a drug supply
486	486	for which reimbursement will be allowed, or a promotion of one
487	487	participating pharmacy over another by these methods.
488	488	(4)a. Use a covered individual's pharmacy services data
489	489	collected pursuant to the provision of claims processing
490	490	services for the purpose of soliciting, marketing, or
491	491	referring the covered individual to a mail-order pharmacy or
492	492	PBM affiliate.
493	493	b. This subdivision shall not limit a health benefit
494	494	plan's use of pharmacy services data for the purpose of
495	495	administering the health benefit plan.
496	496	c. This subdivision shall not prohibit a pharmacy
497	497	benefits manager from notifying a covered individual that a
498	498	less costly option for a specific prescription drug is
499	499	available through a mail-order pharmacy or PBM affiliate,
500	500	provided the notification shall state that switching to the
501	501	less costly option is not mandatory. The commissioner, by
502	502	rule, may determine the language of the notification
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532	532	rule, may determine the language of the notification
533	533	authorized under this paragraph made by a pharmacy benefits
534	534	manager to a covered individual.
535	535	(5) Require a covered individual to make a payment for
536	536	a prescription drug at the point of sale in an amount that
537	537	exceeds the lessorlesser of the following:
538	538	a. The contracted cost share amount.
539	539	b. An amount an individual would pay for a prescription
540	540	if that individual were paying without insurance.
541	541	(6) Increase a covered individual's cost-sharing
542	542	percentage or ratio at or after the point of sale by raising
543	543	the deductible, copayment, or coinsurance, or by requiring any
544	544	other out-of-pocket payment as a means to recoup the
545	545	dispensing cost of a pharmacist or pharmacy. "
546	546	"§27-45A-10
547	547	(a) With respect to a pharmacist or pharmacy, Aa
548	548	pharmacy benefits manager , directly or through an affiliate or
549	549	a contracted third party, may not do any of the following:
550	550	(1) Reimburse an in-network pharmacy or pharmacist in
551	551	the state an amount less than the amount that the pharmacy
552	552	benefits manager reimburses a similarly situated PBM affiliate
553	553	for providing the same pharmacist services to covered
554	554	individuals in the same health benefit plan.
555	555	(2) Reimburse an in-network pharmacy or pharmacist for
556	556	a drug in an amount that is less than or exceeds the actual
557	557	acquisition cost plus the cost of dispensing pursuant to
558	558	Section 27-45A-13.
559	559	(3) Practice spread pricing in this state.
560	560	(2)(4) Deny a pharmacy or pharmacist the right to
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590	590	(2)(4) Deny a pharmacy or pharmacist the right to
591	591	participate as a contractnetwork provider if the pharmacy or
592	592	pharmacist meets and agrees to the terms and conditions,
593	593	including reimbursements, in the pharmacy benefits manager's
594	594	contract.
595	595	(3)(5) Impose credentialing standards on a pharmacist
596	596	or pharmacy beyond or more onerous than the licensing
597	597	standards set by the Alabama State Board of Pharmacy or charge
598	598	a pharmacy or pharmacist aany fee in connection with in regard
599	599	to, without limitation, network enrollment, network
600	600	participation, credentialing or recredentialing, change of
601	601	ownership, submission of claims, adjudication of claims,
602	602	claims processed through discount card programs, or otherwise,
603	603	if not in conjunction with an audit conducted pursuant to
604	604	Article 8 of Chapter 23 of Title 34, provided that this
605	605	subdivision shall not prohibit a pharmacy benefits manager
606	606	from setting minimum requirements for participating in a
607	607	pharmacy network.
608	608	(4)(6) Prohibit a pharmacist or pharmacy , while filling
609	609	a prescription for a covered individual, regardless of payment
610	610	source, from providing athe covered individual specific
611	611	information on the amount of the covered individual's cost
612	612	share for the covered individual's prescription drug and the
613	613	clinical efficacy of a more affordable alternative drug if one
614	614	is available, or penalize a pharmacist or pharmacy for
615	615	disclosing this information to a covered individual or for
616	616	selling to a covered individual a more affordable alternative
617	617	if one is available with any relevant information about the
618	618	prescription, including the following:
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648	648	prescription, including the following:
649	649	a. The cost and reimbursement amount of the drug.
650	650	b. An alternative drug.
651	651	c. Any other information considered to be necessary in
652	652	the professional judgment of the pharmacist .
653	653	(5)(7) Prohibit a pharmacist or pharmacy from offering
654	654	and providing delivery services to a covered individual as an
655	655	ancillary service of the pharmacy, provided all of the
656	656	following requirements are met:
657	657	a. The pharmacist or pharmacy can demonstrate quality,
658	658	stability, and safety standards during delivery.
659	659	b. The pharmacist or pharmacy does not charge any
660	660	delivery or service fee to a pharmacy benefits manager or
661	661	health insurer.
662	662	c. The pharmacist or pharmacy alerts the covered
663	663	individual that he or she will be responsible for any delivery
664	664	service fee associated with the delivery service, and that the
665	665	pharmacy benefits manager or health insurer will not reimburse
666	666	the delivery service fee.
667	667	(6)(8) Charge or hold a pharmacist or pharmacy
668	668	responsible for a fee or penalty relating to an audit
669	669	conducted pursuant to The Pharmacy Audit Integrity Act,
670	670	Article 8 of Chapter 23 of Title 34, provided this prohibition
671	671	does not restrict recoupments made in accordance with the
672	672	Pharmacy Audit Integrity Act.
673	673	(7)(9) Charge a pharmacist or pharmacy a point-of-sale
674	674	or retroactive fee or otherwise recoup funds from a pharmacy
675	675	in connection with claims for which the pharmacy has already
676	676	been paid, unless the recoupment is made pursuant to an audit
677	677	309
678	678	310
679	679	311
680	680	312
681	681	313
682	682	314
683	683	315
684	684	316
685	685	317
686	686	318
687	687	319
688	688	320
689	689	321
690	690	322
691	691	323
692	692	324
693	693	325
694	694	326
695	695	327
696	696	328
697	697	329
698	698	330
699	699	331
700	700	332
701	701	333
702	702	334
703	703	335
704	704	336 SB93 INTRODUCED
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706	706	been paid, unless the recoupment is made pursuant to an audit
707	707	conducted in accordance with the Pharmacy Audit Integrity
708	708	ActArticle 8 of Chapter 23 of Title 34 .
709	709	(8)(10) Except for a drug reimbursed, directly or
710	710	indirectly, by the Medicaid program, vary the amount a
711	711	pharmacy benefits manager reimburses an entity for a drug,
712	712	including each and every prescription medication that is
713	713	eligible for specialty tier placement by the Centers for
714	714	Medicare and Medicaid Services pursuant to 42 C.F.R. §
715	715	423.560, regardless of any provision of law to the contrary,
716	716	on the basis of whether:
717	717	a. The drug is subject to an agreement under 42 U.S.C.
718	718	§ 256b; or
719	719	b. The entity participates in the program set forth in
720	720	42 U.S.C. § 256b.
721	721	(9)(11) If an entity participates, directly or
722	722	indirectly, in the program set forth in 42 U.S.C. § 256b, do
723	723	any of the following:
724	724	a. Assess a fee, charge-back, or other adjustment on
725	725	the entity.
726	726	b. Restrict access to the pharmacy benefits manager's
727	727	pharmacy network.
728	728	c. Require the entity to enter into a contract with a
729	729	specific pharmacy to participate in the pharmacy benefits
730	730	manager's pharmacy network.
731	731	d. Create a restriction or an additional charge on a
732	732	patient who chooses to receive drugs from the entity.
733	733	e. Create any additional requirements or restrictions
734	734	on the entity.
735	735	337
736	736	338
737	737	339
738	738	340
739	739	341
740	740	342
741	741	343
742	742	344
743	743	345
744	744	346
745	745	347
746	746	348
747	747	349
748	748	350
749	749	351
750	750	352
751	751	353
752	752	354
753	753	355
754	754	356
755	755	357
756	756	358
757	757	359
758	758	360
759	759	361
760	760	362
761	761	363
762	762	364 SB93 INTRODUCED
763	763	Page 14
764	764	on the entity.
765	765	(10)(12) Require a claim for a drug to include a
766	766	modifier to indicate that the drug is subject to an agreement
767	767	under 42 U.S.C. § 256b.
768	768	(11)(13) Penalize or retaliate against a pharmacist or
769	769	pharmacy for exercising rights under this chapter or the
770	770	Pharmacy Audit Integrity Act. "
771	771	Section 2. Section 27-45A-13 is added to the Code of
772	772	Alabama 1975, to read as follows:
773	773	§27-45A-13
774	774	(a) A pharmacy benefits manager shall include in its
775	775	reimbursement of a prescription drug to a pharmacist or
776	776	pharmacy the cost of a professional dispensing fee as a
777	777	predetermined, average cost that is applied uniformly and
778	778	equally to all network pharmacies, and which shall not be
779	779	below the professional dispensing fee paid by the State of
780	780	Alabama under Title XIX of the federal Social Security Act,
781	781	provided that the cost of the professional dispensing fee
782	782	shall be borne by the pharmacy benefits manager and not the
783	783	covered individual as prohibited under Section 27-45A-8.
784	784	(b)(1) If a pharmacy benefits manager or a payor
785	785	reimburses a pharmacist or pharmacy an amount below the
786	786	pharmacist or pharmacy's dispensing cost for a particular
787	787	drug, the pharmacist or pharmacy may decline to dispense the
788	788	drug to a covered individual and may direct the individual to
789	789	another pharmacist or pharmacy.
790	790	(2) A pharmacy benefits manager may not take any
791	791	retaliatory action against, or impose any penalty on, a
792	792	pharmacy or pharmacist who declines to dispense a drug to a
793	793	365
794	794	366
795	795	367
796	796	368
797	797	369
798	798	370
799	799	371
800	800	372
801	801	373
802	802	374
803	803	375
804	804	376
805	805	377
806	806	378
807	807	379
808	808	380
809	809	381
810	810	382
811	811	383
812	812	384
813	813	385
814	814	386
815	815	387
816	816	388
817	817	389
818	818	390
819	819	391
820	820	392 SB93 INTRODUCED
821	821	Page 15
822	822	pharmacy or pharmacist who declines to dispense a drug to a
823	823	covered individual under subdivision (1), including
824	824	cancellation or nonrenewal of a contract, or bringing a suit
825	825	for breach of contract.
826	826	(c) Subject to state and federal privacy laws, a
827	827	pharmacist or pharmacy may disclose any reimbursement rate for
828	828	its prescription dispensing services to an ultimate payor for
829	829	those services, including an employer, the state, or the
830	830	federal government.
831	831	Section 3. Sections 34-23-181, 34-23-185, and
832	832	34-23-187, Code of Alabama 1975, are amended to read as
833	833	follows:
834	834	"§34-23-181
835	835	The following words shall have the following meanings
836	836	as used in this article:
837	837	(1) COMMISSIONER. The Commissioner of the Department of
838	838	Insurance of the State of Alabama.
839	839	(1)(2) HEALTH BENEFIT PLAN. Any individual or group
840	840	plan, employee welfare benefit plan, policy, or contract for
841	841	health care services issued, delivered, issued for delivery,
842	842	or renewed in this state by a health care insurer, health
843	843	maintenance organization, accident and sickness insurer,
844	844	fraternal benefit society, nonprofit hospital service
845	845	corporation, nonprofit medical service corporation, health
846	846	care service plan, or any other person, firm, corporation,
847	847	joint venture, or other similar business entity that pays for
848	848	insureds or beneficiaries in this state. The term includes,
849	849	but is not limited to, entities created pursuant to Article 6
850	850	of Chapter 20 of Title 10A. A health benefit plan located or
851	851	393
852	852	394
853	853	395
854	854	396
855	855	397
856	856	398
857	857	399
858	858	400
859	859	401
860	860	402
861	861	403
862	862	404
863	863	405
864	864	406
865	865	407
866	866	408
867	867	409
868	868	410
869	869	411
870	870	412
871	871	413
872	872	414
873	873	415
874	874	416
875	875	417
876	876	418
877	877	419
878	878	420 SB93 INTRODUCED
879	879	Page 16
880	880	of Chapter 20 of Title 10A. A health benefit plan located or
881	881	domiciled outside of the State of Alabama is deemed to be
882	882	subject to this article if it receives, processes,
883	883	adjudicates, pays, or denies claims for health care services
884	884	submitted by or on behalf of patients, insureds, or
885	885	beneficiaries who reside in Alabama.
886	886	(2)(3) PHARMACY. A place licensed by the Alabama State
887	887	Board of Pharmacy in which prescriptions, drugs, medicines,
888	888	medical devices, chemicals, and poisons are sold, offered for
889	889	sale, compounded, or dispensed and shall include all places
890	890	whose title may imply the sale, offering for sale,
891	891	compounding, or dispensing of prescriptions, drugs, medicines,
892	892	chemicals, or poisons.
893	893	(3)(4) PHARMACY BENEFITBENEFITS MANAGEMENT PLAN. An
894	894	arrangement for the delivery of pharmacist services in which a
895	895	pharmacy benefitbenefits manager undertakes to administer the
896	896	payment or reimbursement of any of the costs of pharmacist
897	897	services for an enrollee on a prepaid or insured basis that
898	898	contains one or more incentive arrangements intended to
899	899	influence the cost or level of pharmacist services between the
900	900	plan sponsor and one or more pharmacies with respect to the
901	901	delivery of pharmacist services and requires or creates
902	902	benefit payment differential incentives for enrollees to use
903	903	under contract with the pharmacy benefitbenefits manager.
904	904	(4)(5) PHARMACY BENEFITBENEFITS MANAGER. A business
905	905	that administers the prescription drug or device portion of
906	906	pharmacy benefitbenefits management plans or health insurance
907	907	plans on behalf of plan sponsors, insurance companies, unions,
908	908	and health maintenance organizations. The term includes a
909	909	421
910	910	422
911	911	423
912	912	424
913	913	425
914	914	426
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916	916	428
917	917	429
918	918	430
919	919	431
920	920	432
921	921	433
922	922	434
923	923	435
924	924	436
925	925	437
926	926	438
927	927	439
928	928	440
929	929	441
930	930	442
931	931	443
932	932	444
933	933	445
934	934	446
935	935	447
936	936	448 SB93 INTRODUCED
937	937	Page 17
938	938	and health maintenance organizations. The term includes a
939	939	person or entity acting for a pharmacy benefitbenefits manager
940	940	in a contractual or employment relationship in the performance
941	941	of pharmacy benefitbenefits management for a managed care
942	942	company, nonprofit hospital or medical service organization,
943	943	insurance company, or third-party payor.
944	944	(5)(6) PHARMACIST SERVICES. Offering for sale,
945	945	compounding, or dispensing of prescriptions, drugs, medicines,
946	946	chemicals, or poisons pursuant to a prescription. Pharmacist
947	947	services also includes the sale or provision of, counseling
948	948	of, or fitting of medical devices, including prosthetics and
949	949	durable medical equipment."
950	950	"§34-23-185
951	951	(a) Each entity conducting an audit shall establish a
952	952	written appeals process under which a pharmacy may appeal an
953	953	unfavorable preliminary audit report to the entity.
954	954	(b) Following the appeal, if the entity finds that an
955	955	unfavorable audit report or any portion thereof is
956	956	unsubstantiated, the entity shall dismiss the audit report or
957	957	that portion without the necessity of any further action.
958	958	(c)(1) Following the appeal, if any of the issues
959	959	raised in the appeal are not resolved to the satisfaction of
960	960	either party, that party may ask for mediation of those
961	961	unresolved issues unless other remedies are granted under the
962	962	terms of the contract. A certified mediator shall be chosen by
963	963	agreement of the parties from the mediators list maintained by
964	964	the Alabama Supreme Court. The cost of mediation shall be
965	965	borne by agreement of the parties or by the decision of the
966	966	mediator.
967	967	449
968	968	450
969	969	451
970	970	452
971	971	453
972	972	454
973	973	455
974	974	456
975	975	457
976	976	458
977	977	459
978	978	460
979	979	461
980	980	462
981	981	463
982	982	464
983	983	465
984	984	466
985	985	467
986	986	468
987	987	469
988	988	470
989	989	471
990	990	472
991	991	473
992	992	474
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995	995	Page 18
996	996	mediator.
997	997	(2) Notwithstanding subdivision (1), the commissioner
998	998	shall have authority to enforce this article, including any
999	999	action under Chapter 45A of Title 27, and may modify or
1000	1000	reverse the findings of an audit report.
1001	1001	(3) A pharmacist or pharmacy may file a complaint
1002	1002	directly with the commissioner for enforcement of this
1003	1003	article."
1004	1004	"§34-23-187
1005	1005	This article does notshall apply to any audit, review,
1006	1006	or investigation that involves alleged fraud, willful
1007	1007	misrepresentation, or waste abuse that is initiated by a
1008	1008	pharmacy benefits manager ."
1009	1009	Section 4. To add Section 34-23-188 to the Code of
1010	1010	Alabama 1975, to read as follows:
1011	1011	§34-23-188
1012	1012	The Commissioner of Insurance may investigate
1013	1013	complaints of any alleged violation of this article by an
1014	1014	auditing entity that is licensed or regulated under Title 27,
1015	1015	and shall adopt rules to enforce this article.
1016	1016	Section 5. This act shall become effective on October
1017	1017	1, 2025.
1018	1018	477
1019	1019	478
1020	1020	479
1021	1021	480
1022	1022	481
1023	1023	482
1024	1024	483
1025	1025	484
1026	1026	485
1027	1027	486
1028	1028	487
1029	1029	488
1030	1030	489
1031	1031	490
1032	1032	491
1033	1033	492
1034	1034	493
1035	1035	494
1036	1036	495
1037	1037	496
1038	1038	497