First Regular Session
Seventy-fifth General Assembly
STATE OF COLORADO
INTRODUCED
LLS NO. 25-0095.03 Kristen Forrestal x4217
HOUSE BILL 25-1094
House Committees Senate Committees
Health & Human Services
A BILL FOR AN ACT
C
ONCERNING PHARMACY BENEFIT MANAGER P RACTICES THAT AFFECT101
PRESCRIPTION DRUG COSTS .102
Bill Summary
(Note: This summary applies to this bill as introduced and does
not reflect any amendments that may be subsequently adopted. If this bill
passes third reading in the house of introduction, a bill summary that
applies to the reengrossed version of this bill will be available at
http://leg.colorado.gov
.)
The bill:
! Allows a pharmacy benefit manager (PBM) to earn income
derived from the assessment of a flat-dollar service fee;
! Prohibits a PBM from earning income based on the cost of
a prescription drug;
! Prohibits a PBM from designing a formulary to favor a
HOUSE SPONSORSHIP
Brown and Johnson,
SENATE SPONSORSHIP
Pelton B. and Roberts,
Shading denotes HOUSE amendment. Double underlining denotes SENATE amendment.
Capital letters or bold & italic numbers indicate new material to be added to existing law.
Dashes through the words or numbers indicate deletions from existing law. certain branded pharmaceutical or biologic;
! Sets the amount that a PBM shall reimburse an unaffiliated
pharmacy or a PBM-affiliated retail, mail order, or
specialty pharmacy for a prescription drug;
! Requires a PBM to credit income derived from a source
other than a flat-dollar service fee to a health insurance
carrier (carrier) or a self-funded health benefit plan; and
! Requires a PBM to make certain documents and data
available to a carrier, a self-funded plan, or the
commissioner of insurance upon request.
Be it enacted by the General Assembly of the State of Colorado:1
SECTION 1. In Colorado Revised Statutes, add 10-16-122.8 as2
follows:3
10-16-122.8. Pharmacy benefit manager practices -4
agreements - fees - documentation - rules. (1) A
PHARMACY BENEFIT5
MANAGER MAY EARN INCOME DERIVED FROM THE ASSESSMENT OF A6
SINGLE, FLAT-DOLLAR SERVICE FEE FOR THE PROVISION OF A PRESCRIPTION7
DRUG, WHICH SERVICE FEE IS TRANSPARENTLY EXPRESSED IN A WRITTEN8
AGREEMENT BETWEEN THE PBM AND A CARRIER OR A SELF-FUNDED9
HEALTH BENEFIT PLAN. THE SINGLE, FLAT-DOLLAR SERVICE FEE MAY VARY10
FROM CLIENT TO CLIENT BASED ON THE NUMBER OF PLAN PARTICIPANTS ,11
CLINICAL AND ADMINISTRATIVE SERVICES PROVIDED , VALUE-BASED12
PAYMENT ARRANGEMENT , AND OTHER CONSIDERATIONS.13
(2) (a) A
PBM SHALL NOT:14
(I) E
ARN ANY INCOME THAT IS DIRECTLY OR INDIRECTLY BASED ON15
THE NET ACQUISITION COST OF A PRESCRIPTION DRUG, INCLUDING INCOME16
FROM PRESCRIPTION DRUG MARK -UPS, COPAYMENTS THAT EXCEED THE17
COST OF PRESCRIPTION DRUGS, UP-CHARGING OR SPREAD-PRICING, GROUP18
PURCHASING ORGANIZATION REVENUES , MANUFACTURER -DERIVED19
REVENUES, OR ANY OTHER ARRANGEMENTS CONCERNING THE PRICING OF20
HB25-1094-2- PRESCRIPTION DRUGS; OR1
(II) D
ESIGN A PRESCRIPTION DRUG FORMULARY TO FAVOR A2
CERTAIN BRANDED PHARMACEUTICAL OR BIOLOGIC OVER A3
THERAPEUTICALLY EQUIVALENT GENERIC OR BIOSIMILAR , UNLESS THE4
BRANDED PHARMACEUTICAL OR BIOLOGIC HAS A LOWER DISCOUNTED NET5
ACQUISITION COST AND THAT LOWER COST IS REFLECTED IN A LOWER6
OUT-OF-POCKET EXPENSE FOR CONSUMERS .7
(b) T
HIS SUBSECTION (2) DOES NOT PREVENT A PBM FROM8
NEGOTIATING A PRESCRIPTION DRUG REBATE OR OTHER DISCOUNT AS A9
PERCENTAGE OF THE PRESCRIPTION DRUG 'S LIST PRICE.10
(3) (a) A
PBM SHALL REIMBURSE AN UNAFFILIATED PHARMACY OR11
A PBM-AFFILIATED RETAIL, MAIL ORDER, OR SPECIALTY PHARMACY FOR12
THE FULFILLMENT OF A PRESCRIPTION DRUG IN AN AMOUNT EQUAL TO THE13
NATIONAL AVERAGE DRUG ACQUISITION COST FOR THE DISPENSED14
PRESCRIPTION DRUG INGREDIENTS PLUS A TWO -DOLLAR FEE AND A15
PROFESSIONAL DISPENSING FEE AS DETERMINED IN THE PHARMACY16
CONTRACT. IF THE NATIONAL AVERAGE DRUG ACQUISITION COST IS NOT17
AVAILABLE AT THE TIME A PRESCRIPTION DRUG IS ADMINISTERED OR18
DISPENSED, A PBM SHALL NOT REIMBURSE IN AN AMOUNT THAT IS LESS19
THAN THE WHOLESALE ACQUISITION COST OF THE PRESCRIPTION DRUG .20
(b) A
PBM SHALL CREDIT ANY INCOME DERIVED FROM SOURCES21
OTHER THAN THE SINGLE , FLAT-DOLLAR SERVICE FEE DESCRIBED IN22
SUBSECTION (1) OF THIS SECTION TO THE CARRIER OR SELF -FUNDED23
HEALTH BENEFIT PLAN WITH WHICH THE PBM HAS CONTRACTED.24
(4) U
PON REQUEST OF A CARRIER, A SELF-FUNDED HEALTH BENEFIT25
PLAN, A FIDUCIARY OF THE CARRIER OR SELF-FUNDED HEALTH BENEFIT26
PLAN, OR THE COMMISSIONER, A PBM SHALL MAKE AVAILABLE, WITHIN27
HB25-1094
-3- THIRTY DAYS AFTER THE DATE OF THE REQUEST AND WITHOUT CHARGE ,1
DOCUMENTATION AND DATA AS REQUESTED OR AS REQUIRED TO FULFILL2
THE CARRIER'S OR SELF-FUNDED HEALTH BENEFIT PLAN 'S FIDUCIARY3
OBLIGATIONS TO COVERED PERSONS . THE DOCUMENTATION AND DATA4
INCLUDE:5
(a) T
HE AGGREGATE DOLLAR AND PER UNIT AMOUNT OF ALL PBM6
INCOME DERIVED FROM THE FLAT-DOLLAR SERVICE FEE ASSESSED TO THE7
CARRIER OR SELF-FUNDED HEALTH BENEFIT PLAN;8
(b) T
HE PRESCRIPTION DRUG CLAIMS PROCESSED BY THE PBM FOR9
THE CARRIER'S HEALTH BENEFIT PLAN OR THE SELF -FUNDED HEALTH10
BENEFIT PLAN; AND11
(c) T
HE PBM'S REIMBURSEMENTS FOR ALL RETAIL , MAIL ORDER,12
UNAFFILIATED, AND SPECIALTY PHARMACIES THAT FILL PRESCRIPTIONS13
FOR COVERED PERSONS.14
(5) T
HE COMMISSIONER MAY ADOPT RULES AS NECESSARY TO15
ENFORCE THIS SECTION.16
SECTION 2. Act subject to petition - effective date -17
applicability. (1) This act takes effect January 1, 2026; except that, if a18
referendum petition is filed pursuant to section 1 (3) of article V of the19
state constitution against this act or an item, section, or part of this act20
within the ninety-day period after final adjournment of the general21
assembly, then the act, item, section, or part will not take effect unless22
approved by the people at the general election to be held in November23
2026 and, in such case, will take effect on the date of the official24
declaration of the vote thereon by the governor.25
(2) This act applies to conduct occurring on or after the applicable26
effective date of this act.27
HB25-1094
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