Indiana 2025 Regular Session

Indiana House Bill HB1606 Compare Versions

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22 Introduced Version
33 HOUSE BILL No. 1606
44 _____
55 DIGEST OF INTRODUCED BILL
66 Citations Affected: IC 27-1-24.5; IC 27-1-44.5-12; IC 27-1-48.5.
77 Synopsis: Pharmacy benefit managers. Prohibits a pharmacy benefit
88 manager from taking certain actions. Requires a pharmacy benefit
99 manager to submit a report to the insurance commissioner every six
1010 months. (Current law requires a pharmacy benefit manager to submit
1111 the report annually.) Provides that if a contract holder requests an audit
1212 of compliance with the contract from a pharmacy benefit manager, the
1313 pharmacy benefit manager must provide the audit requested to the
1414 contract holder not later than 30 business days after receiving the
1515 request. Removes the provision specifying that the files or forms
1616 disclosed to the contract holder by the pharmacy benefit manager as
1717 part of an audit of compliance with the contract may be modified to
1818 redact trade secrets. Establishes civil penalties that the department of
1919 insurance (department) shall impose for a violation of the provisions
2020 concerning pharmacy benefit managers. Requires a pharmacy benefit
2121 manager to provide additional information in the pharmacy benefit
2222 manager's report to the department. Requires, after June 30, 2025, a
2323 health payer to include information relating to prescription drug pricing
2424 in the data submitted to the all payer claims data base by the health
2525 payer. Requires a health plan to credit toward a covered individual's
2626 deductible and annual maximum out-of-pocket expenses any amount
2727 the covered individual pays directly to any health care provider for a
2828 medically necessary covered health care service if a claim for the
2929 health care service is not submitted to the health plan and the amount
3030 paid by the covered individual to the health care provider is less than
3131 the average discounted rate for the health care service paid to a health
3232 care provider in the health plan's network.
3333 Effective: July 1, 2025; January 1, 2026.
3434 McGuire, Barrett, King, Isa
3535 January 21, 2025, read first time and referred to Committee on Insurance.
3636 2025 IN 1606—LS 7630/DI 141 Introduced
3737 First Regular Session of the 124th General Assembly (2025)
3838 PRINTING CODE. Amendments: Whenever an existing statute (or a section of the Indiana
3939 Constitution) is being amended, the text of the existing provision will appear in this style type,
4040 additions will appear in this style type, and deletions will appear in this style type.
4141 Additions: Whenever a new statutory provision is being enacted (or a new constitutional
4242 provision adopted), the text of the new provision will appear in this style type. Also, the
4343 word NEW will appear in that style type in the introductory clause of each SECTION that adds
4444 a new provision to the Indiana Code or the Indiana Constitution.
4545 Conflict reconciliation: Text in a statute in this style type or this style type reconciles conflicts
4646 between statutes enacted by the 2024 Regular Session of the General Assembly.
4747 HOUSE BILL No. 1606
4848 A BILL FOR AN ACT to amend the Indiana Code concerning
4949 insurance.
5050 Be it enacted by the General Assembly of the State of Indiana:
5151 1 SECTION 1. IC 27-1-24.5-16.5 IS ADDED TO THE INDIANA
5252 2 CODE AS A NEW SECTION TO READ AS FOLLOWS
5353 3 [EFFECTIVE JULY 1, 2025]: Sec. 16.5. As used in this chapter,
5454 4 "spread pricing" means the practice in which a pharmacy benefit
5555 5 manager charges a health plan a different amount for pharmacist
5656 6 services than the amount the pharmacy benefit manager
5757 7 reimburses a pharmacy for the pharmacist services.
5858 8 SECTION 2. IC 27-1-24.5-19, AS AMENDED BY P.L.196-2021,
5959 9 SECTION 22, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
6060 10 JULY 1, 2025]: Sec. 19. (a) A pharmacy benefit manager shall provide
6161 11 equal access and incentives to all pharmacies within the pharmacy
6262 12 benefit manager's network.
6363 13 (b) A pharmacy benefit manager may not do any of the following:
6464 14 (1) Condition participation in any network on accreditation,
6565 15 credentialing, or licensing of a pharmacy, other than a license or
6666 16 permit required by the Indiana board of pharmacy or other state
6767 17 or federal regulatory authority for the services provided by the
6868 2025 IN 1606—LS 7630/DI 141 2
6969 1 pharmacy. However, nothing in this subdivision precludes the
7070 2 department from providing credentialing or accreditation
7171 3 standards for pharmacies.
7272 4 (2) Discriminate against any pharmacy.
7373 5 (3) Directly or indirectly retroactively deny a claim or aggregate
7474 6 of claims after the claim or aggregate of claims has been
7575 7 adjudicated, unless any of the following apply:
7676 8 (A) The original claim was submitted fraudulently.
7777 9 (B) The original claim payment was incorrect because the
7878 10 pharmacy or pharmacist had already been paid for the drug.
7979 11 (C) The pharmacist services were not properly rendered by the
8080 12 pharmacy or pharmacist.
8181 13 (4) Reduce, directly or indirectly, payment to a pharmacy for
8282 14 pharmacist services to an effective rate of reimbursement,
8383 15 including permitting an insurer or plan sponsor to make such a
8484 16 reduction.
8585 17 (5) Reimburse a pharmacy that is affiliated with the pharmacy
8686 18 benefit manager, other than solely being included in the pharmacy
8787 19 benefit manager's network, at a greater reimbursement rate than
8888 20 other pharmacies in the same network.
8989 21 (6) Impose limits, including quantity limits or refill frequency
9090 22 limits, on a pharmacy's access to medication that differ from those
9191 23 existing for a pharmacy benefit manager affiliate.
9292 24 (7) Share any covered individual's information including
9393 25 de-identified covered individual information, received from a
9494 26 pharmacy or pharmacy benefit manager affiliate, except as
9595 27 permitted by the federal Health Insurance Portability and
9696 28 Accountability Act (HIPAA) (P.L.104-191).
9797 29 (8) Require a covered individual, as a condition of payment or
9898 30 reimbursement, to purchase pharmacist services, including
9999 31 prescription drugs, exclusively through a pharmacy benefit
100100 32 manager affiliate.
101101 33 (9) Prohibit or limit any covered individual from selecting an
102102 34 in network pharmacy or pharmacist of the covered
103103 35 individual's choice that meets and agrees to the terms and
104104 36 conditions in the pharmacy benefit manager's contract.
105105 37 (10) Impose a monetary advantage or penalty under a health
106106 38 plan that would affect a covered individual's choice of
107107 39 pharmacy among the pharmacies that have chosen to contract
108108 40 with the pharmacy benefit manager, under the same terms
109109 41 and conditions described in subdivision (9).
110110 42 (11) Retroactively:
111111 2025 IN 1606—LS 7630/DI 141 3
112112 1 (A) impose fees on a pharmacy; or
113113 2 (B) reduce the reimbursement amount for pharmacist
114114 3 services issued by the pharmacy.
115115 4 A violation of this subsection by a pharmacy benefit manager
116116 5 constitutes an unfair or deceptive act or practice in the business of
117117 6 insurance under IC 27-4-1-4.
118118 7 SECTION 3. IC 27-1-24.5-21, AS ADDED BY P.L.68-2020,
119119 8 SECTION 1, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
120120 9 JULY 1, 2025]: Sec. 21. (a) Beginning June 1, 2021, and annually
121121 10 every six (6) months thereafter, a pharmacy benefit manager shall
122122 11 submit a report containing data from the immediately preceding
123123 12 calendar year six (6) months to the commissioner. The commissioner
124124 13 shall determine what must be included in the report and consider the
125125 14 following information to be included in the report:
126126 15 (1) The aggregate amount of all rebates that the pharmacy benefit
127127 16 manager received from all pharmaceutical manufacturers for:
128128 17 (A) all insurers; and
129129 18 (B) each insurer;
130130 19 with which the pharmacy benefit manager contracted during the
131131 20 immediately preceding calendar year. six (6) months.
132132 21 (2) The aggregate amount of administrative fees that the
133133 22 pharmacy benefit manager received from all pharmaceutical
134134 23 manufacturers for:
135135 24 (A) all insurers; and
136136 25 (B) each insurer;
137137 26 with which the pharmacy benefit manager contracted during the
138138 27 immediately preceding calendar year. six (6) months.
139139 28 (3) The aggregate amount of retained rebates that the pharmacy
140140 29 benefit manager received from all pharmaceutical manufacturers
141141 30 and did not pass through to insurers with which the pharmacy
142142 31 benefit manager contracted during the immediately preceding
143143 32 calendar year. six (6) months.
144144 33 (4) The highest, lowest, and mean aggregate retained rebate for:
145145 34 (A) all insurers; and
146146 35 (B) each insurer;
147147 36 with which the pharmacy benefit manager contracted during the
148148 37 immediately preceding calendar year. six (6) months.
149149 38 (b) Except as provided in section 29(b) of this chapter, a
150150 39 pharmacy benefit manager that provides information under this section
151151 40 may designate the information as a trade secret (as defined in
152152 41 IC 24-2-3-2). Information designated as a trade secret under this
153153 42 subsection must not be published unless required under subsection (c).
154154 2025 IN 1606—LS 7630/DI 141 4
155155 1 (c) Except as provided in section 29(b) of this chapter, disclosure
156156 2 of information designated as a trade secret under subsection (b) may be
157157 3 ordered by a court of Indiana for good cause shown or made in a court
158158 4 filing.
159159 5 SECTION 4. IC 27-1-24.5-25, AS AMENDED BY P.L.152-2024,
160160 6 SECTION 12, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
161161 7 JULY 1, 2025]: Sec. 25. (a) A contract holder may, one (1) time in a
162162 8 calendar year and not earlier than six (6) months following a previously
163163 9 requested audit, request an audit of compliance with the contract. If
164164 10 requested by the contract holder, the audit shall include full disclosure
165165 11 of the following data specific to the contract holder:
166166 12 (1) Rebate amounts secured on prescription drugs, whether
167167 13 product specific or general rebates, that were provided by a
168168 14 pharmaceutical manufacturer. The information provided under
169169 15 this subdivision must identify the prescription drugs by
170170 16 therapeutic category.
171171 17 (2) Pharmaceutical and device claims received by the pharmacy
172172 18 benefit manager on any of the following:
173173 19 (A) The CMS-1500 form or its successor form.
174174 20 (B) The HCFA-1500 form or its successor form.
175175 21 (C) The HIPAA X12 837P electronic claims transaction for
176176 22 professional services, or its successor transaction.
177177 23 (D) The HIPAA X12 837I institutional form or its successor
178178 24 form.
179179 25 (E) The CMS-1450 form or its successor form.
180180 26 (F) The UB-04 form or its successor form.
181181 27 The forms or transaction may be modified as necessary to comply
182182 28 with the federal Health Insurance Portability and Accountability
183183 29 Act (HIPAA) (P.L. 104-191). or to redact a trade secret (as
184184 30 defined in IC 24-2-3-2).
185185 31 (3) Pharmaceutical and device claims payments or electronic
186186 32 funds transfer or remittance advice notices provided by the
187187 33 pharmacy benefit manager as ASC X12N 835 files or a successor
188188 34 format. The files may be modified as necessary to comply with
189189 35 the federal Health Insurance Portability and Accountability Act
190190 36 (HIPAA) (P.L. 104-191). or to redact a trade secret (as defined in
191191 37 IC 24-2-3-2). In the event that paper claims are provided, the
192192 38 pharmacy benefit manager shall convert the paper claims to the
193193 39 ASC X12N 835 electronic format or a successor format.
194194 40 (4) Any other revenue and fees derived by the pharmacy benefit
195195 41 manager from the contract, including all direct and indirect
196196 42 remuneration from pharmaceutical manufacturers regardless of
197197 2025 IN 1606—LS 7630/DI 141 5
198198 1 whether the remuneration is classified as a rebate, fee, or another
199199 2 term.
200200 3 (b) A pharmacy benefit manager may not impose the following:
201201 4 (1) Fees for:
202202 5 (A) requesting an audit under this section; or
203203 6 (B) selecting an auditor other than an auditor designated by the
204204 7 pharmacy benefit manager.
205205 8 (2) Conditions that would restrict a contract holder's right to
206206 9 conduct an audit under this section, including restrictions on the:
207207 10 (A) time period of the audit;
208208 11 (B) number of claims analyzed;
209209 12 (C) type of analysis conducted;
210210 13 (D) data elements used in the analysis; or
211211 14 (E) selection of an auditor as long as the auditor:
212212 15 (i) does not have a conflict of interest;
213213 16 (ii) meets a threshold for liability insurance specified in the
214214 17 contract between the parties;
215215 18 (iii) does not work on a contingent fee basis; and
216216 19 (iv) does not have a history of breaching nondisclosure
217217 20 agreements.
218218 21 (c) A pharmacy benefit manager shall disclose, upon request from
219219 22 a contract holder, to the contract holder the actual amounts directly or
220220 23 indirectly paid by the pharmacy benefit manager to the pharmacist or
221221 24 pharmacy for the drug and for pharmacist services related to the drug.
222222 25 (d) A pharmacy benefit manager shall provide notice to a contract
223223 26 holder contracting with the pharmacy benefit manager of any
224224 27 consideration, including direct or indirect remuneration, that the
225225 28 pharmacy benefit manager receives from a pharmaceutical
226226 29 manufacturer or group purchasing organization for formulary
227227 30 placement or any other reason.
228228 31 (e) The commissioner may establish a procedure to release
229229 32 information from an audit performed by the department to a contract
230230 33 holder that has requested an audit under this section in a manner that
231231 34 does not violate confidential or proprietary information laws.
232232 35 (f) A contract that is entered into, issued, amended, or renewed after
233233 36 June 30, 2024, may not contain a provision that violates this section.
234234 37 (g) A pharmacy benefit manager shall:
235235 38 (1) obtain any information requested in an audit under this section
236236 39 from a group purchasing organization or other partner entity of
237237 40 the pharmacy benefit manager; and
238238 41 (2) confirm receipt of a request for an audit under this section to
239239 42 the contract holder not later than ten (10) business days after the
240240 2025 IN 1606—LS 7630/DI 141 6
241241 1 information is requested; and
242242 2 (3) provide the audit requested under this section to the
243243 3 contract holder not later than thirty (30) business days after
244244 4 receiving the request.
245245 5 (h) Information provided in an audit under this section must be
246246 6 provided in accordance with the federal Health Insurance Portability
247247 7 and Accountability Act (HIPAA) (P.L. 104-191).
248248 8 SECTION 5. IC 27-1-24.5-27.7 IS ADDED TO THE INDIANA
249249 9 CODE AS A NEW SECTION TO READ AS FOLLOWS
250250 10 [EFFECTIVE JULY 1, 2025]: Sec. 27.7. A pharmacy benefit
251251 11 manager may not engage in spread pricing.
252252 12 SECTION 6. IC 27-1-24.5-28, AS ADDED BY P.L.68-2020,
253253 13 SECTION 1, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
254254 14 JANUARY 1, 2026]: Sec. 28. (a) A violation of this chapter is an
255255 15 unfair or deceptive act or practice in the business of insurance under
256256 16 IC 27-4-1-4.
257257 17 (b) The department may also adopt rules under IC 4-22-2 to set forth
258258 18 fines for a violation under this chapter.
259259 19 (b) Except as provided in subsections (c) and (d), the
260260 20 department shall impose a civil penalty for a violation of this
261261 21 chapter, in the following amounts:
262262 22 (1) One thousand dollars ($1,000) for the first violation.
263263 23 (2) Five thousand dollars ($5,000) for the second violation.
264264 24 (3) Ten thousand dollars ($10,000) for each additional
265265 25 violation.
266266 26 (c) If a pharmacy benefit manager has been assessed a civil
267267 27 penalty under subsection (b) for a violation of this chapter, the
268268 28 pharmacy benefit manager shall have thirty (30) calendar days to
269269 29 correct the violation before the pharmacy benefit manager may be
270270 30 assessed another civil penalty under subsection (b).
271271 31 (d) If a pharmacy benefit manager has been assessed a civil
272272 32 penalty under subsection (b) for a violation of this chapter that
273273 33 resulted from a clerical error or unintentional omission on the part
274274 34 of the pharmacy benefit manager, the department shall not
275275 35 escalate the civil penalty imposed on the pharmacy benefit
276276 36 manager under subsection (b).
277277 37 (e) If a pharmacy benefit manager has been assessed multiple
278278 38 civil penalties for violations of this chapter, the department may
279279 39 revoke the pharmacy benefit manager's license issued by the
280280 40 commissioner under section 18 of this chapter.
281281 41 SECTION 7. IC 27-1-24.5-29, AS ADDED BY P.L.166-2023,
282282 42 SECTION 1, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
283283 2025 IN 1606—LS 7630/DI 141 7
284284 1 JULY 1, 2025]: Sec. 29. (a) At least every six (6) months, a pharmacy
285285 2 benefit manager shall provide a report to the department.
286286 3 (b) A report under subsection (a) must include the following
287287 4 information:
288288 5 (1) The overall aggregate amount charged to a health plan for all
289289 6 pharmaceutical claims processed by the pharmacy benefit
290290 7 manager for the immediately preceding six (6) months. and
291291 8 (2) The overall aggregate amount paid to pharmacies for claims
292292 9 processed by the pharmacy benefit manager for the immediately
293293 10 preceding six (6) months.
294294 11 (3) The overall aggregate amount of all rebates that the
295295 12 pharmacy benefit manager received from all pharmaceutical
296296 13 manufacturers for:
297297 14 (A) all insurers; and
298298 15 (B) each insurer;
299299 16 with which the pharmacy benefit manager contracted during
300300 17 the immediately preceding six (6) months.
301301 18 (4) The overall aggregate amount of administrative fees that
302302 19 the pharmacy benefit manager received from all
303303 20 pharmaceutical manufacturers for:
304304 21 (A) all insurers; and
305305 22 (B) each insurer;
306306 23 with which the pharmacy benefit manager contracted during
307307 24 the immediately preceding six (6) months.
308308 25 (5) The overall aggregate amount of retained rebates that the
309309 26 pharmacy benefit manager received from all pharmaceutical
310310 27 manufacturers and did not pass through to insurers with
311311 28 which the pharmacy benefit manager contracted during the
312312 29 immediately preceding six (6) months.
313313 30 (c) Upon request, the department shall make a report received under
314314 31 subsection (a) available to the members of the general assembly in an
315315 32 electronic format under IC 5-14-6.
316316 33 SECTION 8. IC 27-1-44.5-12 IS ADDED TO THE INDIANA
317317 34 CODE AS A NEW SECTION TO READ AS FOLLOWS
318318 35 [EFFECTIVE JULY 1, 2025]: Sec. 12. After June 30, 2025, a health
319319 36 payer shall include in the data submitted to the data base under
320320 37 this chapter the following pricing information relating to a
321321 38 prescription drug covered by the health payer:
322322 39 (1) The wholesale price.
323323 40 (2) The retail price.
324324 41 (3) The negotiated price.
325325 42 SECTION 9. IC 27-1-48.5 IS ADDED TO THE INDIANA CODE
326326 2025 IN 1606—LS 7630/DI 141 8
327327 1 AS A NEW CHAPTER TO READ AS FOLLOWS [EFFECTIVE
328328 2 JULY 1, 2025]:
329329 3 Chapter 48.5. Out-of-Pocket Expense Credit
330330 4 Sec. 1. This chapter applies to a health plan entered into or
331331 5 renewed after June 30, 2025.
332332 6 Sec. 2. As used in this chapter, "covered individual" means an
333333 7 individual entitled to coverage under a health plan.
334334 8 Sec. 3. As used in this chapter, "health care provider" means an
335335 9 individual or entity that is licensed, certified, registered, or
336336 10 regulated by an entity described in IC 25-0.5-11.
337337 11 Sec. 4. (a) As used in this chapter, "health care services" means
338338 12 any services or products rendered by a health care provider within
339339 13 the scope of the provider's license or legal authorization.
340340 14 (b) The term includes hospital, medical, surgical, and
341341 15 pharmaceutical services or products.
342342 16 Sec. 5. (a) As used in this chapter, "health plan" means any of
343343 17 the following:
344344 18 (1) A self-insurance program established under IC 5-10-8-7(b)
345345 19 to provide group coverage.
346346 20 (2) A prepaid health care delivery plan through which health
347347 21 services are provided under IC 5-10-8-7(c).
348348 22 (3) A policy of accident and sickness insurance as defined in
349349 23 IC 27-8-5-1, but not including any insurance, plan, or policy
350350 24 set forth in IC 27-8-5-2.5(a).
351351 25 (4) An individual contract (as defined in IC 27-13-1-21) or a
352352 26 group contract (as defined in IC 27-13-1-16) with a health
353353 27 maintenance organization that provides coverage for basic
354354 28 health care services (as defined in IC 27-13-1-4).
355355 29 (5) A self-funded health benefit plan that complies with the
356356 30 federal Employee Retirement Income Security Act (ERISA)
357357 31 of 1974 (29 U.S.C. 1001 et seq.).
358358 32 (b) The term includes a person that administers any of the
359359 33 following:
360360 34 (1) A self-insurance program established under IC 5-10-8-7(b)
361361 35 to provide group coverage.
362362 36 (2) A prepaid health care delivery plan through which health
363363 37 services are provided under IC 5-10-8-7(c).
364364 38 (3) A policy of accident and sickness insurance as defined in
365365 39 IC 27-8-5-1, but not including any insurance, plan, or policy
366366 40 set forth in IC 27-8-5-2.5(a).
367367 41 (4) An individual contract (as defined in IC 27-13-1-21) or a
368368 42 group contract (as defined in IC 27-13-1-16) with a health
369369 2025 IN 1606—LS 7630/DI 141 9
370370 1 maintenance organization that provides coverage for basic
371371 2 health care services (as defined in IC 27-13-1-4).
372372 3 (5) A self-funded health benefit plan that complies with the
373373 4 federal Employee Retirement Income Security Act (ERISA)
374374 5 of 1974 (29 U.S.C. 1001 et seq.).
375375 6 Sec. 6. As used in this chapter, "network" means a group of
376376 7 health care providers that:
377377 8 (1) provide health care services to covered individuals; and
378378 9 (2) have agreed to, or are otherwise subject to, maximum
379379 10 limits on the prices for the health care services to be provided
380380 11 to the covered individuals.
381381 12 Sec. 7. A health plan shall credit toward a covered individual's
382382 13 deductible and annual maximum out-of-pocket expenses any
383383 14 amount the covered individual pays directly to any health care
384384 15 provider for a medically necessary covered health care service if a
385385 16 claim for the health care service is not submitted to the health plan
386386 17 and the amount paid by the covered individual to the health care
387387 18 provider is less than the average discounted rate for the health care
388388 19 service paid to a health care provider in the health plan's network.
389389 20 Sec. 8. A health plan shall:
390390 21 (1) establish a procedure by which a covered individual may
391391 22 claim a credit under section 7 of this chapter; and
392392 23 (2) identify documentation necessary to support a claim for a
393393 24 credit under section 7 of this chapter.
394394 25 Sec. 9. A health plan shall display information about the
395395 26 procedure and documentation described in section 8 of this chapter
396396 27 on its website.
397397 28 Sec. 10. The department shall adopt rules under IC 4-22-2 to
398398 29 effectuate the provisions of this chapter.
399399 30 SECTION 10. [EFFECTIVE JULY 1, 2025] (a) The Indiana
400400 31 department of insurance shall amend its administrative rules to
401401 32 conform with IC 27-1-24.5-28, as amended by this act.
402402 33 (b) The Indiana department of insurance shall begin the process
403403 34 of amending its administrative rules under subsection (a) not later
404404 35 than December 31, 2025.
405405 36 (c) This SECTION expires July 1, 2028.
406406 2025 IN 1606—LS 7630/DI 141