Colorado 2025 Regular Session

Colorado House Bill HB1094 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1	1		First Regular Session
2	2		Seventy-fifth General Assembly
3	3		STATE OF COLORADO
4		-	~~REENGROSSED~~
5		-	This Version Includes All Amendments
6		-	~~Adopted~~ in the House of Introduction
	4	+	ENGROSSED
	5	+	This Version Includes All Amendments Adopted
	6	+	on Second Reading in the House of Introduction
7	7		LLS NO. 25-0095.03 Kristen Forrestal x4217
8	8		HOUSE BILL 25-1094
9	9		House Committees Senate Committees
10	10		Health & Human Services
11	11		Appropriations
12	12		A BILL FOR AN ACT
13	13		C
14	14		ONCERNING PHARMACY BENEFIT MANAGER P RACTICES THAT AFFECT101
15	15		PRESCRIPTION DRUG COSTS .102
16	16		Bill Summary
17	17		(Note: This summary applies to this bill as introduced and does
18	18		not reflect any amendments that may be subsequently adopted. If this bill
19	19		passes third reading in the house of introduction, a bill summary that
20	20		applies to the reengrossed version of this bill will be available at
21	21		http://leg.colorado.gov
22	22		.)
23	23		The bill:
24	24		! Allows a pharmacy benefit manager (PBM) to earn income
25	25		derived from the assessment of a flat-dollar service fee;
26	26		! Prohibits a PBM from earning income based on the cost of
27	27		a prescription drug;
28	28		! Prohibits a PBM from designing a formulary to favor a
29	29		HOUSE
30		-	3rd Reading Unamended
31		-	March 17, 2025
32		-	HOUSE
33	30		Amended 2nd Reading
34	31		March 14, 2025
35	32		HOUSE SPONSORSHIP
36		-	Brown and Johnson, Bacon, Bird, Boesenecker, Duran, English, Joseph, Lieder, Lindsay,
37		-	McCluskie, McCormick, Paschal, Sirota, Smith, Stewart K., Valdez, Woodrow, Zokaie
	33	+	Brown and Johnson,
38	34		SENATE SPONSORSHIP
39	35		Pelton B. and Roberts,
40	36		Shading denotes HOUSE amendment. Double underlining denotes SENATE amendment.
41	37		Capital letters or bold & italic numbers indicate new material to be added to existing law.
42	38		Dashes through the words or numbers indicate deletions from existing law. certain branded pharmaceutical or biologic;
43	39		! Sets the amount that a PBM shall reimburse an unaffiliated
44	40		pharmacy or a PBM-affiliated retail, mail order, or
45	41		specialty pharmacy for a prescription drug;
46	42		! Requires a PBM to credit income derived from a source
47	43		other than a flat-dollar service fee to a health insurance
48	44		carrier (carrier) or a self-funded health benefit plan; and
49	45		! Requires a PBM to make certain documents and data
50	46		available to a carrier, a self-funded plan, or the
51	47		commissioner of insurance upon request.
52	48		Be it enacted by the General Assembly of the State of Colorado:1
53	49		SECTION 1. In Colorado Revised Statutes, add 10-16-122.8 as2
54	50		follows:3
55	51		10-16-122.8. Pharmacy benefit manager practices -4
56	52		agreements - fees - documentation - rules. (1) A
57	53		PHARMACY BENEFIT5
58	54		MANAGER MAY EARN INCOME DERIVED FROM THE ASSESSMENT OF A6
59	55		SINGLE, FLAT-DOLLAR SERVICE FEE FOR THE PROVISION OF A PRESCRIPTION7
60	56		DRUG, WHICH SERVICE FEE IS TRANSPARENTLY EXPRESSED IN A WRITTEN8
61	57		AGREEMENT BETWEEN THE PBM AND
62	58		HEALTH BENEFIT PLAN. THE9
63	59		SINGLE, FLAT-DOLLAR SERVICE FEE MAY VARY FROM CLIENT TO CLIENT OF10
64	60		THE PBM BASED ON THE NUMBER OF HEALTH BENEFIT PLAN11
65	61		PARTICIPANTS, CLINICAL AND ADMINISTRATIVE SERVICES PROVIDED ,12
66	62		VALUE-BASED PAYMENT ARRANGEMENT , AND OTHER CONSIDERATIONS.13
67	63		(2) (a) THROUGHOUT THE COURSE OF PROVIDING PRESCRIPTION14
68	64		DRUG BENEFITS AND CLAIMS PROCESSING SERVICES FOR HEALTH BENEFIT15
69	65		PLANS, A PBM SHALL NOT:16
70	66		(I) E
71	67		ARN ANY INCOME THAT IS DIRECTLY OR INDIRECTLY BASED ON17
72	68		THE NET ACQUISITION COST OF A PRESCRIPTION DRUG, INCLUDING INCOME18
73	69		FROM PRESCRIPTION DRUG MARK -UPS, COPAYMENTS THAT EXCEED THE19
74	70		COST OF PRESCRIPTION DRUGS, UP-CHARGING OR SPREAD-PRICING, GROUP20
75	71		1094-2- PURCHASING ORGANIZATION REVENUES , MANUFACTURER -DERIVED1
76	72		REVENUES, OR ANY OTHER ARRANGEMENTS CONCERNING THE PRICING OF2
77	73		PRESCRIPTION DRUGS; OR3
78	74		(II) D
79	75		ESIGN A PRESCRIPTION DRUG FORMULARY TO FAVOR A4
80	76		CERTAIN BRANDED PHARMACEUTICAL OR BIOLOGIC OVER A5
81	77		THERAPEUTICALLY EQUIVALENT GENERIC OR BIOSIMILAR , UNLESS THE6
82	78		BRANDED PHARMACEUTICAL OR BIOLOGIC HAS A LOWER
83	79		NET7
84	80		ACQUISITION COST AND THAT LOWER COST IS REFLECTED IN A LOWER8
85	81		OUT-OF-POCKET EXPENSE FOR CONSUMERS .9
86	82		(b) IF A PBM, WHICH MAY BE A PARENT OR SUBSIDIARY ENTITY TO10
87	83		OR OTHERWISE INTEGRATED WITH AN INSURANCE CARRIER THAT OFFERS11
88	84		A HEALTH BENEFIT PLAN, INADVERTENTLY COLLECTS INCOME DERIVED12
89	85		FROM SOURCES PROHIBITED BY SUBSECTION (2)(a)(I) OF THIS SECTION, THE13
90	86		PBM SHALL PASS THE INCOME THROUGH TO THE HEALTH BENEFIT PLAN14
91	87		BENEFICIARIES.15
92	88		(c) A PBM MUST BE REIMBURSED BY A HEALTH BENEFIT PLAN FOR16
93	89		LOWERING AGGREGATED PRESCRIPTION DRUG SPENDING FOR THE PLAN17
94	90		OVER A GIVEN PERIOD OF TIME. A PBM MUST ALSO BE REIMBURSED FOR18
95	91		THE DIRECT SERVICES THE PBM PROVIDES TO THE HEALTH BENEFIT PLAN.19
96	92		(d) A PBM MAY INCLUDE IN ITS CONTRACTS OR OTHER20
97	93		AGREEMENTS WITH PRESCRIPTION DRUG MANUFACTURERS PROVISIONS21
98	94		THAT LIMIT THE INCREASE OF THE WHOLESALE ACQUISITION COST OF22
99	95		PRESCRIPTION DRUGS THAT THEY INCLUDE IN THEIR FORMULARIES AND23
100	96		BENEFIT DESIGNS.24
101	97		(e) THIS SUBSECTION (2) DOES NOT PREVENT A PBM FROM25
102	98		NEGOTIATING A PRESCRIPTION DRUG REBATE OR OTHER DISCOUNT AS A26
103	99		PERCENTAGE OF THE PRESCRIPTION DRUG 'S LIST PRICE.27
104	100		1094
105	101		-3- (3) THROUGHOUT THE COURSE OF PROVIDING PRESCRIPTION DRUG1
106	102		BENEFITS AND CLAIMS PROCESSING SERVICES FOR HEALTH BENEFIT PLANS,2
107	103		A PBM SHALL REIMBURSE AN UNAFFILIATED PHARMACY OR A3
108	104		PBM-
109	105		AFFILIATED RETAIL, MAIL ORDER, OR SPECIALTY PHARMACY FOR THE4
110	106		FULFILLMENT OF A PRESCRIPTION DRUG IN AN AMOUNT EQUAL TO THE5
111	107		NATIONAL AVERAGE DRUG ACQUISITION COST FOR THE DISPENSED6PRESCRIPTION DRUG INGREDIENTS AND A REASONABLE AND ADEQUATE7
112	108		DISPENSING FEE. IF THE NATIONAL AVERAGE DRUG ACQUISITION COST IS8
113	109		NOT AVAILABLE AT THE TIME A PRESCRIPTION DRUG IS ADMINISTERED OR9
114	110		DISPENSED, A PBM SHALL NOT REIMBURSE IN AN AMOUNT THAT IS LESS10
115	111		THAN THE WHOLESALE ACQUISITION COST OF THE PRESCRIPTION DRUG .11
116	112		12
117	113		(4) (a) A CONTRACT BETWEEN A PBM AND A COVERED PERSON'S13
118	114		HEALTH BENEFIT PLAN MUST INCLUDE A PROVISION THAT REQUIRES THE14
119	115		PBM TO DISCLOSE PRESCRIPTION DRUG COST INFORMATION TO THE15
120	116		HEALTH BENEFIT PLAN, INCLUDING CLAIMS-LEVEL PHARMACY DATA AND16
121	117		PBM INCOME DERIVED FROM PROHIBITED SOURCES THAT THE PBM MUST17
122	118		PASS THROUGH TO THE HEALTH BENEFITS PLAN IN ACCORDANCE WITH18
123	119		SUBSECTION (2)(b) OF THIS SECTION. THE INFORMATION MUST BE19
124	120		PROVIDED WITHIN THIRTY DAYS AFTER THE DATE OF THE NOTIFICATION TO20
125	121		THE PBM BY THE HEALTH BENEFIT PLAN OR AT REGULAR NEGOTIATED21
126	122		REPORTING INTERVALS NECESSARY FOR THE HEALTH BENEFIT PLAN TO22
127	123		DETERMINE THE PBM'S COMPLIANCE WITH THE CONTRACT TERMS AND23
128	124		THIS SECTION. THE PBM SHALL ASSESS NO ADDITIONAL FEES WITH24
129	125		REGARD TO PROVISION OF THIS INFORMATION .25
130	126		(b) THE CONTRACT BETWEEN THE PBM AND A COVERED PERSON'S26
131	127		HEALTH BENEFIT PLAN MUST INCLUDE A PROVISION AUTHORIZING THE27
132	128		1094
133	129		-4- COVERED PERSON'S HEALTH BENEFIT PLAN TO ANNUALLY EXECUTE AN1
134	130		AUDIT FOR THE PURPOSE OF VALIDATING COMPLIANCE WITH CONTRACT2
135	131		TERMS AND THIS SECTION.3
136	132		(5) T
137	133		HE COMMISSIONER MAY ADOPT RULES AS NECESSARY TO4
138	134		ENFORCE THIS SECTION.5
139	135		SECTION 2. Act subject to petition - effective date -6
140	136		applicability. (1) This act takes effect
141	137		January 1, 2027; except that, if a7
142	138		referendum petition is filed pursuant to section 1 (3) of article V of the8
143	139		state constitution against this act or an item, section, or part of this act9
144	140		within the ninety-day period after final adjournment of the general10
145	141		assembly, then the act, item, section, or part will not take effect unless11
146	142		approved by the people at the general election to be held in November12
147	143		2026 and, in such case, will take effect January 1, 2027, or on the date of13
148	144		the official declaration of the vote thereon by the governor, whichever is14
149	145		later.15
150	146		(2) This act applies to conduct occurring on or after the applicable16
151	147		effective date of this act.17
152	148		1094
153	149		-5-