SB93INTRODUCED
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SB93
LUDQAAA-1
By Senators Jones, Butler, Beasley, Stewart, Chesteen, Kelley,
Barfoot, Allen, Price
RFD: Banking and Insurance
First Read: 04-Feb-25
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6 LUDQAAA-1 02/04/2025 JC (L)lg 2025-541
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First Read: 04-Feb-25
SYNOPSIS:
Pharmacy benefits managers are third-party
administrators of prescription drug benefits in a
health insurance plan. They are primarily responsible
for processing and paying prescription drug claims.
They typically negotiate price discounts and rebates
from manufacturers and determine how pharmacies get
reimbursed for dispensing prescriptions. Under state
law, pharmacy benefits managers are licensed and
regulated by the Department of Insurance.
This bill would prohibit pharmacy benefits
managers from reimbursing a pharmacy less than the
actual acquisition cost paid by the pharmacy and would
prohibit pharmacy benefits managers from charging
pharmacies or pharmacists miscellaneous fees related to
network participation and claims processing.
This bill would permit pharmacists to disclose
information to consumers about drug prices and
alternative drugs for treatment.
This bill would recognize the right of a
pharmacy to refuse to dispense a drug when the pharmacy
would be reimbursed less than a pharmacy's dispensing
cost, and would further prohibit a pharmacy benefits
manager from recovering the pharmacy's dispensing cost
by requiring a consumer to pay a higher deductible or
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by requiring a consumer to pay a higher deductible or
copayment.
This bill would specify that the Commissioner of
Insurance may enforce violations of the Alabama
Pharmacy Benefits Manager Licensure and Regulation Act
committed by a pharmacy benefits manager during an
audit of a pharmacy, and may also enforce the Pharmacy
Audit Integrity Act in relation to auditing of a
pharmacy by a pharmacy benefits manager.
A BILL
TO BE ENTITLED
AN ACT
Relating to pharmacy benefits managers; to amend
Sections 27-45A-3, 27-45A-6, 27-45A-7, 27-45A-8, and
27-45A-10, Code of Alabama 1975; to further regulate pharmacy
benefits managers in relation to pharmacies and pharmacists;
to further regulate reimbursement by pharmacy benefits
managers to pharmacies; to prohibit pharmacy benefits managers
from charging pharmacies certain fees; to permit pharmacists
to disclose drug information to covered individuals; to add
Section 27-45A-13 to the Code of Alabama 1975, to provide
circumstances when pharmacies may refuse to dispense drugs; to
amend Sections 34-23-181 and 34-23-185, Code of Alabama 1975,
to authorize the Commissioner of Insurance to enforce the
Pharmacy Audit Integrity Act; and to amend Section 34-23-187,
Code of Alabama 1975, to provide that an investigation into
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Code of Alabama 1975, to provide that an investigation into
fraud, waste, or abuse by a pharmacy benefits manager falls
under the Pharmacy Audit Integrity Act; and to add Section
34-23-188, to authorize the Commissioner of Insurance to
investigate complaints concerning an entity licensed by the
Department of Insurance that audits a pharmacy.
BE IT ENACTED BY THE LEGISLATURE OF ALABAMA:
Section 1. Sections 27-45A-3, 27-45A-6, 27-45A-7,
27-45A-8, and 27-45A-10, Code of Alabama 1975, are amended to
read as follows:
"§27-45A-3
For purposes of this chapter, the following words shall
have the following meanings:
(1) ACTUAL ACQUISITION COST. The Average Acquisition
Cost (AAC) of a drug for the State of Alabama, as published by
the Alabama Medicaid Agency. If no AAC is available, the term
means the wholesale acquisition cost (WAC + 0%).
(2) AFFILIATE or PBM AFFILIATE. An entity, including,
but not limited to, a pharmacy, health insurer, or group
purchasing organization that directly or indirectly, through
one or more intermediaries, has one of the following
affiliations:
a. Owns, controls, or has an investment interest in a
pharmacy benefits manager.
b. Is owned, controlled by, or has an investment
interest holder who is a pharmacy benefits manager.
c. Is under common ownership or corporate control with
a pharmacy benefits manager.
(1)(3) CLAIMS PROCESSING SERVICES. The administrative
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(1)(3) CLAIMS PROCESSING SERVICES. The administrative
services performed in connection with the processing and
adjudicating of claims relating to pharmacist services that
include any of the following:
a. Receiving payments for pharmacist services.
b. Making payments to pharmacists or pharmacies for
pharmacist services.
c. Both paragraphs a. and b.
(2)(4) COVERED INDIVIDUAL. A member, policyholder,
subscriber, enrollee, beneficiary, dependent, or other
individual participating in a health benefit plan.
(3)(5) HEALTH BENEFIT PLAN. A policy, contract,
certificate, or agreement entered into, offered, or issued by
a payor or health insurer to provide, deliver, arrange for,
pay for, or reimburse any of the costs of physical, mental, or
behavioral health care services , including pharmaceutical
services.
(4)(6) HEALTH INSURER. An entity subject to the
insurance laws of this state and rules of the department, or
subject to the jurisdiction of the department, that contracts
or offers to contract to provide, deliver, arrange for, pay
for, or reimburse any of the costs of health care services,
including, but not limited to, a sickness and accident
insurance company, a health maintenance organization operating
pursuant to Chapter 21A, a nonprofit hospital or health
service corporation, a health care service plan organized
pursuant to Article 6, Chapter 20 of Title 10A, or any other
entity providing a plan of health insurance, health benefits,
or health services.
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or health services.
(7) IN-NETWORK or NETWORK. A network of pharmacists or
pharmacies that are paid for pharmacist services pursuant to
an agreement with a health benefit plan or a pharmacy benefits
manager.
(5)(8) OTHER PRESCRIPTION DRUG OR DEVICE SERVICES.
Services, other than claims processing services, provided
directly or indirectly, whether in connection with or separate
from claims processing services, including, but not limited
to, any of the following:
a. Negotiating rebates , discounts, or other financial
incentives and arrangements with drug companies.
b. Disbursing or distributing rebates.
c. Managing or participating in incentive programs or
arrangements for pharmacist services.
d. Negotiating or entering into contractual
arrangements with pharmacists or pharmacies, or both.
e. Developing formularies.
f. Designing prescription benefit programs.
g. Advertising or promoting services.
(9) PAYOR. Any entity other than a health insurer
involved in the financing or payment of pharmacist services.
(6)(10) PHARMACIST. As defined in Section 34-23-1.
(7)(11) PHARMACIST SERVICES. Products, goods, and
services, or any combination of products, goods, and services,
provided as a part of the practice of pharmacy.
(8)(12) PHARMACY. As defined in Section 34-23-1.
(9)(13) PHARMACY BENEFITS MANAGER. a. A person,
including a wholly or partially owned or controlled subsidiary
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including a wholly or partially owned or controlled subsidiary
of a pharmacy benefits manager, that provides claims
processing services or other prescription drug or device
services, or both, to covered individuals who are employed in
or are residents of this state, for health benefit plans. The
term includes any person that administers a prescription
discount program directly for or on behalf of a pharmacy
benefits manager or health benefit plan for drugs to covered
individuals which are not reimbursed by a pharmacy benefits
manager or are not covered by a health benefit plan.
b. Pharmacy benefits manager does not include any of
the following:
1. A healthcarehealth care facility licensed in this
state.
2. A healthcarehealth care professional licensed in
this state.
3. A consultant who only provides advice as to the
selection or performance of a pharmacy benefits manager.
(10) PBM AFFILIATE. A pharmacy or pharmacist that,
directly or indirectly, through one or more intermediaries, is
owned or controlled by, or is under common control by, a
pharmacy benefits manager.
(11)(14) PRESCRIPTION DRUGS. Includes, but is not
limited to, certain infusion, compounded, and long-term care,
and specialty prescription drugs . The term does not include
specialty drugs.
(15) REBATE. Any payments or price concessions that
accrue to a pharmacy benefits manager or its health benefit
plan client, directly or indirectly, including through its PBM
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plan client, directly or indirectly, including through its PBM
affiliate or its subsidiary, third party, or intermediary,
including an off-shore purchasing organization, from a
pharmaceutical manufacturer or its affiliate, subsidiary,
third party, or intermediary. The term includes, but is not
limited to, payments, discounts, administration fees, credits,
incentives, or penalties associated, directly or indirectly,
in any way with claims administered on behalf of a health
benefit plan.
(12)(16) SPECIALTY DRUGS. Prescription medications that
require special handling, administration, or monitoring and
are used for the treatment of patients with serious health
conditions requiring complex therapies, and that are eligible
for specialty tier placement by the Centers for Medicare and
Medicaid Services pursuant to 42 C.F.R. § 423.560 .
(17) SPREAD PRICING. A prescription drug pricing model
used by a pharmacy benefits manager in which the pharmacy
benefits manager charges a health benefit plan a contracted
price for prescription drugs that differs from the amount the
pharmacy benefits manager pays the pharmacy for the
prescription drug, including any post-sale or
post-adjudication fees, discounts, or adjustments where not
prohibited by law ."
"§27-45A-6
(a) Nothing in this chapter is intended or shall be
construed to do any of the following:
(1) Bebe in conflict with existing relevant federal
law.
(2) Apply to any specialty drug.
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(2) Apply to any specialty drug.
(3) Impact or impact the ability of a hospital to
mandate its employees ' use of a hospital-owned pharmacy.
(b) The following provisions shall not apply to the
administration by a person of any term, including prescription
drug benefits, of a self-funded health benefit plan that is
governed by the federal Employee Retirement Income Security
Act of 1974, 29 U.S.C. §1001 et. seq.:
(1) Subdivisions (1) and (5) of Section 27-45A-8.
(2) Subdivisions (2), (3), (6), and (7) of Section
27-45A-10."
"§27-45A-7
ReservedIn addition to any other remedy provided by
law, a pharmacist, pharmacy, or covered individual who is
aggrieved by a violation of this chapter may bring a civil
action against a pharmacy benefits manager for damages or
equitable remedies ."
"§27-45A-8
With respect to a covered individual, Aa pharmacy
benefits manager , directly or through an affiliate or a
contracted third party, may not do any of the following:
(1) Require a covered individual, as a condition of
payment or reimbursement, to purchase pharmacist services,
including, but not limited to, prescription drugs, exclusively
through a mail-order pharmacy or pharmacy benefits manager
affiliate.
(2) Prohibit or limit any covered individual from
selecting an in-network pharmacy or pharmacist of his or her
choice who meets and agrees to the terms and conditions,
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choice who meets and agrees to the terms and conditions,
including reimbursements, in the pharmacy benefits manager's
contract.
(3) Impose a monetary advantage or penalty under a
health benefit plan that would affect a covered individual's
choice of pharmacy among those pharmacies that have chosen to
contract with the pharmacy benefits manager under the same
terms and conditions, including reimbursements. For purposes
of this subdivision, "monetary advantage or penalty" includes,
but is not limited to, a higher copayment, a waiver of a
copayment, a reduction in reimbursement services, a
requirement or limit on the number of days of a drug supply
for which reimbursement will be allowed, or a promotion of one
participating pharmacy over another by these methods.
(4)a. Use a covered individual's pharmacy services data
collected pursuant to the provision of claims processing
services for the purpose of soliciting, marketing, or
referring the covered individual to a mail-order pharmacy or
PBM affiliate.
b. This subdivision shall not limit a health benefit
plan's use of pharmacy services data for the purpose of
administering the health benefit plan.
c. This subdivision shall not prohibit a pharmacy
benefits manager from notifying a covered individual that a
less costly option for a specific prescription drug is
available through a mail-order pharmacy or PBM affiliate,
provided the notification shall state that switching to the
less costly option is not mandatory. The commissioner, by
rule, may determine the language of the notification
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rule, may determine the language of the notification
authorized under this paragraph made by a pharmacy benefits
manager to a covered individual.
(5) Require a covered individual to make a payment for
a prescription drug at the point of sale in an amount that
exceeds the lessorlesser of the following:
a. The contracted cost share amount.
b. An amount an individual would pay for a prescription
if that individual were paying without insurance.
(6) Increase a covered individual's cost-sharing
percentage or ratio at or after the point of sale by raising
the deductible, copayment, or coinsurance, or by requiring any
other out-of-pocket payment as a means to recoup the
dispensing cost of a pharmacist or pharmacy. "
"§27-45A-10
(a) With respect to a pharmacist or pharmacy, Aa
pharmacy benefits manager , directly or through an affiliate or
a contracted third party, may not do any of the following:
(1) Reimburse an in-network pharmacy or pharmacist in
the state an amount less than the amount that the pharmacy
benefits manager reimburses a similarly situated PBM affiliate
for providing the same pharmacist services to covered
individuals in the same health benefit plan.
(2) Reimburse an in-network pharmacy or pharmacist for
a drug in an amount that is less than or exceeds the actual
acquisition cost plus the cost of dispensing pursuant to
Section 27-45A-13.
(3) Practice spread pricing in this state.
(2)(4) Deny a pharmacy or pharmacist the right to
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(2)(4) Deny a pharmacy or pharmacist the right to
participate as a contractnetwork provider if the pharmacy or
pharmacist meets and agrees to the terms and conditions,
including reimbursements, in the pharmacy benefits manager's
contract.
(3)(5) Impose credentialing standards on a pharmacist
or pharmacy beyond or more onerous than the licensing
standards set by the Alabama State Board of Pharmacy or charge
a pharmacy or pharmacist aany fee in connection with in regard
to, without limitation, network enrollment, network
participation, credentialing or recredentialing, change of
ownership, submission of claims, adjudication of claims,
claims processed through discount card programs, or otherwise,
if not in conjunction with an audit conducted pursuant to
Article 8 of Chapter 23 of Title 34, provided that this
subdivision shall not prohibit a pharmacy benefits manager
from setting minimum requirements for participating in a
pharmacy network.
(4)(6) Prohibit a pharmacist or pharmacy , while filling
a prescription for a covered individual, regardless of payment
source, from providing athe covered individual specific
information on the amount of the covered individual's cost
share for the covered individual's prescription drug and the
clinical efficacy of a more affordable alternative drug if one
is available, or penalize a pharmacist or pharmacy for
disclosing this information to a covered individual or for
selling to a covered individual a more affordable alternative
if one is available with any relevant information about the
prescription, including the following:
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prescription, including the following:
a. The cost and reimbursement amount of the drug.
b. An alternative drug.
c. Any other information considered to be necessary in
the professional judgment of the pharmacist .
(5)(7) Prohibit a pharmacist or pharmacy from offering
and providing delivery services to a covered individual as an
ancillary service of the pharmacy, provided all of the
following requirements are met:
a. The pharmacist or pharmacy can demonstrate quality,
stability, and safety standards during delivery.
b. The pharmacist or pharmacy does not charge any
delivery or service fee to a pharmacy benefits manager or
health insurer.
c. The pharmacist or pharmacy alerts the covered
individual that he or she will be responsible for any delivery
service fee associated with the delivery service, and that the
pharmacy benefits manager or health insurer will not reimburse
the delivery service fee.
(6)(8) Charge or hold a pharmacist or pharmacy
responsible for a fee or penalty relating to an audit
conducted pursuant to The Pharmacy Audit Integrity Act,
Article 8 of Chapter 23 of Title 34, provided this prohibition
does not restrict recoupments made in accordance with the
Pharmacy Audit Integrity Act.
(7)(9) Charge a pharmacist or pharmacy a point-of-sale
or retroactive fee or otherwise recoup funds from a pharmacy
in connection with claims for which the pharmacy has already
been paid, unless the recoupment is made pursuant to an audit
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been paid, unless the recoupment is made pursuant to an audit
conducted in accordance with the Pharmacy Audit Integrity
ActArticle 8 of Chapter 23 of Title 34 .
(8)(10) Except for a drug reimbursed, directly or
indirectly, by the Medicaid program, vary the amount a
pharmacy benefits manager reimburses an entity for a drug,
including each and every prescription medication that is
eligible for specialty tier placement by the Centers for
Medicare and Medicaid Services pursuant to 42 C.F.R. §
423.560, regardless of any provision of law to the contrary,
on the basis of whether:
a. The drug is subject to an agreement under 42 U.S.C.
§ 256b; or
b. The entity participates in the program set forth in
42 U.S.C. § 256b.
(9)(11) If an entity participates, directly or
indirectly, in the program set forth in 42 U.S.C. § 256b, do
any of the following:
a. Assess a fee, charge-back, or other adjustment on
the entity.
b. Restrict access to the pharmacy benefits manager's
pharmacy network.
c. Require the entity to enter into a contract with a
specific pharmacy to participate in the pharmacy benefits
manager's pharmacy network.
d. Create a restriction or an additional charge on a
patient who chooses to receive drugs from the entity.
e. Create any additional requirements or restrictions
on the entity.
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on the entity.
(10)(12) Require a claim for a drug to include a
modifier to indicate that the drug is subject to an agreement
under 42 U.S.C. § 256b.
(11)(13) Penalize or retaliate against a pharmacist or
pharmacy for exercising rights under this chapter or the
Pharmacy Audit Integrity Act. "
Section 2. Section 27-45A-13 is added to the Code of
Alabama 1975, to read as follows:
§27-45A-13
(a) A pharmacy benefits manager shall include in its
reimbursement of a prescription drug to a pharmacist or
pharmacy the cost of a professional dispensing fee as a
predetermined, average cost that is applied uniformly and
equally to all network pharmacies, and which shall not be
below the professional dispensing fee paid by the State of
Alabama under Title XIX of the federal Social Security Act,
provided that the cost of the professional dispensing fee
shall be borne by the pharmacy benefits manager and not the
covered individual as prohibited under Section 27-45A-8.
(b)(1) If a pharmacy benefits manager or a payor
reimburses a pharmacist or pharmacy an amount below the
pharmacist or pharmacy's dispensing cost for a particular
drug, the pharmacist or pharmacy may decline to dispense the
drug to a covered individual and may direct the individual to
another pharmacist or pharmacy.
(2) A pharmacy benefits manager may not take any
retaliatory action against, or impose any penalty on, a
pharmacy or pharmacist who declines to dispense a drug to a
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pharmacy or pharmacist who declines to dispense a drug to a
covered individual under subdivision (1), including
cancellation or nonrenewal of a contract, or bringing a suit
for breach of contract.
(c) Subject to state and federal privacy laws, a
pharmacist or pharmacy may disclose any reimbursement rate for
its prescription dispensing services to an ultimate payor for
those services, including an employer, the state, or the
federal government.
Section 3. Sections 34-23-181, 34-23-185, and
34-23-187, Code of Alabama 1975, are amended to read as
follows:
"§34-23-181
The following words shall have the following meanings
as used in this article:
(1) COMMISSIONER. The Commissioner of the Department of
Insurance of the State of Alabama.
(1)(2) HEALTH BENEFIT PLAN. Any individual or group
plan, employee welfare benefit plan, policy, or contract for
health care services issued, delivered, issued for delivery,
or renewed in this state by a health care insurer, health
maintenance organization, accident and sickness insurer,
fraternal benefit society, nonprofit hospital service
corporation, nonprofit medical service corporation, health
care service plan, or any other person, firm, corporation,
joint venture, or other similar business entity that pays for
insureds or beneficiaries in this state. The term includes,
but is not limited to, entities created pursuant to Article 6
of Chapter 20 of Title 10A. A health benefit plan located or
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of Chapter 20 of Title 10A. A health benefit plan located or
domiciled outside of the State of Alabama is deemed to be
subject to this article if it receives, processes,
adjudicates, pays, or denies claims for health care services
submitted by or on behalf of patients, insureds, or
beneficiaries who reside in Alabama.
(2)(3) PHARMACY. A place licensed by the Alabama State
Board of Pharmacy in which prescriptions, drugs, medicines,
medical devices, chemicals, and poisons are sold, offered for
sale, compounded, or dispensed and shall include all places
whose title may imply the sale, offering for sale,
compounding, or dispensing of prescriptions, drugs, medicines,
chemicals, or poisons.
(3)(4) PHARMACY BENEFITBENEFITS MANAGEMENT PLAN. An
arrangement for the delivery of pharmacist services in which a
pharmacy benefitbenefits manager undertakes to administer the
payment or reimbursement of any of the costs of pharmacist
services for an enrollee on a prepaid or insured basis that
contains one or more incentive arrangements intended to
influence the cost or level of pharmacist services between the
plan sponsor and one or more pharmacies with respect to the
delivery of pharmacist services and requires or creates
benefit payment differential incentives for enrollees to use
under contract with the pharmacy benefitbenefits manager.
(4)(5) PHARMACY BENEFITBENEFITS MANAGER. A business
that administers the prescription drug or device portion of
pharmacy benefitbenefits management plans or health insurance
plans on behalf of plan sponsors, insurance companies, unions,
and health maintenance organizations. The term includes a
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and health maintenance organizations. The term includes a
person or entity acting for a pharmacy benefitbenefits manager
in a contractual or employment relationship in the performance
of pharmacy benefitbenefits management for a managed care
company, nonprofit hospital or medical service organization,
insurance company, or third-party payor.
(5)(6) PHARMACIST SERVICES. Offering for sale,
compounding, or dispensing of prescriptions, drugs, medicines,
chemicals, or poisons pursuant to a prescription. Pharmacist
services also includes the sale or provision of, counseling
of, or fitting of medical devices, including prosthetics and
durable medical equipment."
"§34-23-185
(a) Each entity conducting an audit shall establish a
written appeals process under which a pharmacy may appeal an
unfavorable preliminary audit report to the entity.
(b) Following the appeal, if the entity finds that an
unfavorable audit report or any portion thereof is
unsubstantiated, the entity shall dismiss the audit report or
that portion without the necessity of any further action.
(c)(1) Following the appeal, if any of the issues
raised in the appeal are not resolved to the satisfaction of
either party, that party may ask for mediation of those
unresolved issues unless other remedies are granted under the
terms of the contract. A certified mediator shall be chosen by
agreement of the parties from the mediators list maintained by
the Alabama Supreme Court. The cost of mediation shall be
borne by agreement of the parties or by the decision of the
mediator.
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mediator.
(2) Notwithstanding subdivision (1), the commissioner
shall have authority to enforce this article, including any
action under Chapter 45A of Title 27, and may modify or
reverse the findings of an audit report.
(3) A pharmacist or pharmacy may file a complaint
directly with the commissioner for enforcement of this
article."
"§34-23-187
This article does notshall apply to any audit, review,
or investigation that involves alleged fraud, willful
misrepresentation, or waste abuse that is initiated by a
pharmacy benefits manager ."
Section 4. To add Section 34-23-188 to the Code of
Alabama 1975, to read as follows:
§34-23-188
The Commissioner of Insurance may investigate
complaints of any alleged violation of this article by an
auditing entity that is licensed or regulated under Title 27,
and shall adopt rules to enforce this article.
Section 5. This act shall become effective on October
1, 2025.
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