HB 1850 — Modifies provisions relating to pharmacy benefits managers

IfAudit anreports audit report is not delivered to the pharmacy withinin the time frame required under this subdivision,timeline the audit shall be deemed freeto ofhave discrepancies,no discrepancies and no recoupment shall be permitted;made;

HB[(11)] 1850(17) 4Notwithstanding [(11)]any (18)other Theprovision days'in supplythis forsubsection, unit-of-usethe items,entity suchconducting asthe topicals,audit drops,shall vials,not anduse inhalants,the shallaccounting notpractice beof limitedextrapolation beyondin manufacturercalculating recommendations;recoupments or penalties for audits, except as otherwise authorized under subdivision (5) of this subsection;

(18) The days' supply for unit-of-use items, such as topicals, drops, vials, and inhalants, shall not be limited beyond manufacturer recommendations;

HCS HBs 1850 & 1975 5 (20) If the only commercially available package size exceeds an entity's maximum days' supply and the entity accepts the refill of such prescription, the entity shall not recoup such claim as an early refill;

and (22) AnIn entity conducting a wholesale invoice audit shallconducted complyby withan theentity: following provisions:

(a) TheAn entity shall not audit the claims of another entity;

The National Drug Code for the dispensed drug is in a quantity that is a subunitsub- unit or multiple of the purchased drug as reflected on a supporting wholesale invoice;

and (d) Within five business days of anya request by the audited pharmacy, the entity shall provide supporting documentation provided to the entity by the audited pharmacy's suppliers;suppliers.

and (23) Notwithstanding any other provision in this subsection, the entity conducting the audit shall not use the accounting practice of extrapolation in calculating recoupments or penalties for audits, except as otherwise authorized under subdivision (5) of this subsection.

Should the identified discrepancy for an individual audit exceed twenty-five HB 1850 5 thousand dollars, future payments to the pharmacy in excess of twenty-five thousand dollars may be withheld pending finalization of the audit.

[3.]4.[3.] 4.

IfSuch any recoupment occurred, the report shall include the total amount of recoupment returned to the plan sponsor.sponsor, if any.

HCS HBs 1850 & 1975 6 [5.] 6.

[6.][6.]7. 7.

338.840.

The department of health and senior services shall establish a critical access care pharmacy program to ensure the sustainability of critical access care pharmacies throughout this state.

The program shall assist pharmacies identified as critical access care pharmacies based on their location in an area where pharmacy services are needed.

376.387.

1.

For purposes of this section, the following terms shall mean:

(1) "Covered person", [the same meaning as such term is defined in section 376.1257] a policyholder, subscriber, enrollee, or other individual whose prescription drug coverage is administered through a pharmacy benefits manager or a health benefit plan;

(2) "Health benefit plan", the same meaning as such term is defined in section 376.1350;

(3) "Health carrier" or "carrier", the same meaning as such term is defined in section 376.1350;

(4) "Pharmacy", the same meaning as such term is defined in chapter 338;

(5) "Pharmacy benefits manager", the same meaning as such term is defined in section 376.388.

2.

No pharmacy benefits manager shall include a provision in a contract entered into or modified on or after August 28, 2018, with a pharmacy or pharmacist that requires a covered person to make a payment for a prescription drug at the point of sale in an amount that exceeds the lesser of:

(1) The copayment amount as required under the health benefit plan;

or (2) The amount an individual would pay for a prescription if that individual paid with cash.

HB 1850 6 3.

A pharmacy or pharmacist shall have the right to provide to a covered person information regarding the amount of the covered person's cost share for a prescription drug, the covered person's cost of an alternative drug, and the covered person's cost of the drug without adjudicating the claim through the pharmacy benefits manager.

Neither a pharmacy nor a pharmacist shall be proscribed by a pharmacy benefits manager from discussing any such information or from selling a more affordable alternative to the covered person.

4.

No pharmacy benefits manager shall, directly or indirectly, charge or hold a pharmacist or pharmacy responsible for any fee amount related to a claim that is not known at the time of the claim's adjudication, unless the amount is a result of improperly paid claims or charges for administering a health benefit plan.

5.

This section shall not apply with respect to claims under Medicare Part D, or any other plan administered or regulated solely under federal law, and to the extent this section may be preempted under the Employee Retirement Income Security Act of 1974 for self- funded employer-sponsored health benefit plans.

6.

A pharmacy benefits manager shall notify in writing any health carrier with which it contracts if the pharmacy benefits manager has a conflict of interest, any commonality of ownership, or any other relationship, financial or otherwise, between the pharmacy benefits manager and any other health carrier with which the pharmacy benefits manager contracts.

7.

The department of commerce and insurance shall enforce this section and may audit any information provided by a pharmacy benefits manager under this section.

(1) "Contracted"Affiliated pharmacy"pharmacy", [or "pharmacy"], a pharmacy locatedthat indirectly Missourior participatingindirectly, inthrough theone networkor ofmore aintermediaries, pharmacyowns benefitsor managercontrols, throughis aowned director controlled by, or indirectis contract;under common ownership or control with a pharmacy benefits manager;

(2) ["Health"Contracted carrier",pharmacy" an[or entity"pharmacy"], subjecta topharmacy thelocated insurancein lawsMissouri andparticipating regulationsin of this state that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costsnetwork of health care services, including a sicknesspharmacy andbenefits accidentmanager insurancethrough company, a healthdirect maintenance organization, a nonprofit hospital and health service corporation, or anyindirect othercontract; entity providing a plan of health insurance, health benefits, or health services, except that such plan shall not include any coverage pursuant to a liability insurance policy, workers' compensation insurance policy, or medical payments insurance issued as a supplement to a liability policy] "Health benefit plan", the same meaning given to the term in section 376.1350;

[(2)] (3) "Maximum"Health allowablecarrier", cost",an entity subject to the per-unitinsurance amountlaws and regulations of this state that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a pharmacysickness benefitsand manageraccident reimbursesinsurance company, a pharmacisthealth formaintenance organization, a prescriptionnonprofit drug,hospital excludingand health service corporation, or any other entity providing a dispensingplan of health insurance, health benefits, or professionalhealth fee;services, except that such plan shall not include any coverage pursuant to a liability insurance policy, workers' compensation insurance policy, or medical payments insurance issued as a supplement to a liability policy;

HB[(3)] 1850 7 (4) "Maximum allowable costcost", list"the orper-unit "MACamount list",that a listingpharmacy ofbenefits drugmanager productsreimburses thata meetpharmacist thefor standarda describedprescription indrug, thisexcluding section;a dispensing or professional fee;

(5)[(4)](5) "Pharmacy","Maximum asallowable suchcost termlist" isor defined"MAC list", a listing of drug products that meet the standard described in chapterthis 338;section;

[(5)] (6) "Pharmacy"Pharmacy", benefitsas manager",such anterm entityis thatdefined contractsin withchapter pharmacies338; on behalf of health carriers [or any health plan sponsored by the state or a political subdivision of the state] or health benefit plans to provide prescription drug and pharmacist services;

[(6)] (7) "Pharmacy benefits managermanager", affiliate"an orentity "affiliate",that acontracts pharmacywith orpharmacies pharmaciston thatbehalf directlyof orhealth indirectly,carriers through[or oneany orhealth moreplan intermediaries,sponsored ownsby the state or controls,a ispolitical ownedsubdivision orof controlledthe by,state] or ishealth underbenefit commonplans ownershipto orprovide controlprescription withdrug aand pharmacypharmacist benefitsservices. manager;

(8) "Pharmacy benefits manager rebate aggregator", any entity that negotiates with a pharmaceutical manufacturer on behalf of a pharmacy benefits manager for a rebate;

(9) "Pharmacy claims data", information regarding a prescription transaction that is adjudicated by a pharmacy benefits manager for a covered person, as defined in section 376.387, between the pharmacy and the pharmacy benefits manager and between the pharmacy benefits manager and the plan sponsor, which shall include, at a minimum:

(a) The prescription drug's National Drug Code;

(b) The contracted compensation rate to the plan sponsor for each drug;

(c) The amount paid to the pharmacy for each unit;

(d) The channel of dispensing, whether by retail, mail-order, or specialty pharmacy;

(e) For brand-name drugs, the wholesale acquisition cost per unit;

(f) For generic drugs, the average wholesale price per unit;

(g) The number of claims, participants, dosage units dispensed, and days' supply;

(h) The net price of the drug after accounting for all rebates, including from pharmacy benefits manager rebate aggregators, discounts, and fees;

(i) The total out-of-pocket cost paid by the participant per claim;

and (j)All amounts received by the plan sponsor, the pharmacy benefits manager, or any affiliate including, but not limited to, co-payment assistance, co-payment cards, or remuneration provided by pharmaceutical manufacturers;

(10) "Plan sponsor", any sponsor of a health benefit plan;

(11) "Rebate", any discount, negotiated concession, or other payment provided by a pharmaceutical manufacturer, pharmacy, or health benefit plan to an entity to sell, HB 1850 8 provide, pay, or reimburse a pharmacy or other entity for the dispensation or administration of a prescription drug on behalf of itself or another entity.

and (2) Maintain a procedure to eliminate products from the maximum allowable cost list of drugs subject to such pricing or modify maximum allowable cost pricing at least every HCS HBs 1850 & 1975 7 seven days, if such drugs do not meet the standards and requirements of this section, in order to remain consistent with pricing changes in the marketplace.

HB 1850 9 (2) Apply the adjusted maximum allowable cost price to all similarly situated pharmacies as determined by the pharmacy benefits manager;

A pharmacy benefits manager shall provide each plan sponsorsponsors with thesuch plan sponsor's pharmacy claims data as reasonably requested by thea plan sponsor.

HCS HBs 1850 & 1975 8 10.

AnThe entitypharmacy shallbenefits definemanager andor applyplan thesponsor termshall "rebate"provide as having the sameplan meaningsponsor givenand todepartment theof termcommerce inand thisinsurance sectiondocumentation ifof theany entitybenefit entersdesign intothat aencourages contract to sell, provide, pay, negotiate rebates for, or reimburserequires aenrollees pharmacy,to pharmacyfill benefitsprescriptions manager,at pharmacyaffiliated benefitspharmacies. manager affiliate, or pharmacy benefits manager rebate aggregator for prescription drugs on behalf of itself or another entity.

A pharmacy benefits manager shall provideexercise eachgood planfaith sponsor and fair dealing in the departmentadministration of commercepharmacy benefits and insuranceshall withensure documentationthat of any benefitconflicts designof interest that encouragesmay clinically or requiresfinancially enrolleesimpact tocovered fillpatients prescriptionsor atthe itshealth affiliates.benefit plan sponsor in a negative manner are disclosed.

AAll pharmacydisclosures benefitsrequired managerunder shallthis owesection ashall fiduciarybe dutyprovided to eachthe plan sponsor.sponsor or its authorized agent in a universal manner.

AllIfa disclosurespharmacy requiredbenefits manager or health plan has an affiliated pharmacy or a pharmacy under thiscommon sectionownership, shallthe bepharmacy providedbenefits manager shall disclose to the plan sponsor orand itsthe authorizeddepartment agentof incommerce aand universallyinsurance: accessible format.

(1) The amount charged per dosage unit to the affiliated pharmacy;

and (2) The median amount charged per dosage unit at nonaffiliated, in-network pharmacies.

IfThe adepartment pharmacyof benefitscommerce managerand hasinsurance anmay affiliate,audit the pharmacy benefits managermanagers shall disclose to theensure plancompliance sponsorwith andthis thesection. department of commerce and insurance:

(1)376.394. The amount charged per dosage unit to the affiliate;

and1. (2) The median amount charged per dosage unit at in-network pharmacies that are not affiliates.

15.As used in this section, the following terms shall mean:

The(1) department"Critical-access ofcare commercepharmacy", anda insuranceMissouri-domiciled maypharmacy auditwith a pharmacyphysical benefitslocation managerin tothe ensurestate complianceof withMissouri thisthat section.employs fewer than five hundred employees across common ownership and that is:

(a) Located in:

a.

A county or city with fewer than fifty thousand residents;

or b.

A county or city with fifty thousand or more residents and in an area within Missouri that is designated as a Primary Care or Mental Health Health Professional Shortage Area (HPSA) or a Medically Underserved Area by the Health Resources and Services Administration (HRSA), an agency of the U.S.

Department of Health and Human Services;

or (b) Any essential retail pharmacy as defined in Section 1860D-42 of the Social Security Act, 42 U.S.C.

Section 1395w-152, as amended by Pub.

L.

119-75;

(2) "Similarly situated", a critical-access care pharmacy:

(a) That is in any of the pharmacy benefits manager's networks;

(b) That purchases the particular drug or medical product or device to which the finding applies from the same pharmaceutical wholesaler as the pharmacy that prevailed in the appeal;

and (c) To which the pharmacy benefits manager also applies the challenged rate of reimbursement or actual cost.

HCS HBs 1850 & 1975 9 2.

Notwithstanding any provision of law to the contrary, a pharmacy benefits manager shall not reimburse a critical-access care pharmacy for a prescription drug or device an amount that is less than the actual cost to that pharmacy for the prescription drug or device plus a professional dispensing fee of ten dollars and fifty cents per claim.

The following provisions shall apply:

(1) A pharmacy benefits manager shall establish a process for a pharmacy to appeal a reimbursement for failing to pay at least the actual cost and dispensing fee to the critical-access care pharmacy for the prescription drug or device and shall permit a critical-access care pharmacy or its designated agent to file an appeal using the standard appeal form described in this section;

(2) If a critical-access care pharmacy chooses to contest a reimbursement for failing to pay at least the actual cost the critical-access care pharmacy incurred for a particular drug or medical product or device, the critical-access care pharmacy has the right to designate a pharmacy services administrative organization or other agent to file and handle its appeal;

and (3) The department of commerce and insurance shall create and make available to pharmacy benefits managers and covered entities a standard form to be used by a critical-access care pharmacy or its designated agent to file an appeal pursuant to this subsection with a pharmacy benefits manager or covered entity.

3.

If a critical-access care pharmacy or agent acting on behalf of a critical-access care pharmacy prevails in an appeal provided for in this section, the pharmacy benefits manager or covered entity shall, within seven business days after notice of the appeal is received by the pharmacy benefits manager or covered entity:

(1) Make the necessary change to the challenged rate of reimbursement or actual cost;

(2) If the product involved in the appeal is a drug, provide to the critical-access care pharmacy or agent the National Drug Code number for the drug on which the change is based;

(3) Permit the challenging critical-access care pharmacy to reverse and rebill the claim upon which the appeal is based;

(4) Pay or waive the cost of any transaction fee required to reverse and rebill the claim;

(5) Reimburse the critical-access care pharmacy at least in an amount equal to the critical-access care pharmacy's actual cost for the prescription drug or device;

and (6) Apply the findings from the appeal as to the rate of reimbursement and actual cost for the particular drug or medical product or device to other similarly situated critical-access care pharmacies.

HCS HBs 1850 & 1975 10 4.

It is a violation of this section if, after an appeal in which a pharmacy or agent acting on behalf of a critical-access care pharmacy prevails, a pharmacy benefits manager or covered entity fails to reimburse the critical-access care pharmacy at least actual cost.

5.

If a critical-access care pharmacy or agent acting on behalf of a critical-access care pharmacy loses or is denied an appeal provided for in this section, the following provisions shall apply:

(1) If the product associated with the National Drug Code number or unique device identifier is available at a cost that is less than the challenged rate of reimbursement from a pharmaceutical wholesaler in this state, the pharmacy benefits manager or covered entity shall, within seven business days after notice of the appeal is received by the pharmacy benefits manager or covered entity, provide the appealing critical-access care pharmacy or agent with:

(a) The name of the national or regional pharmaceutical wholesalers operating in this state that have the particular drug or medical product or device currently in stock at a price that is less than the amount of the challenged rate of reimbursement;

and (b) If the product involved in the appeal is a drug, the National Drug Code number for the drug;

or (c) If the product involved is a medical device, the unique device identifier for the device;

and (2) If the product associated with the National Drug Code number or unique device identifier is not available at a cost that is less than the challenged rate of reimbursement from the pharmaceutical wholesaler from whom the critical-access care pharmacy purchases the majority of prescription pharmaceutical products for resale, the pharmacy benefits manager shall adjust the challenged rate of reimbursement to an amount equal to or greater than the appealing critical-access care pharmacy's actual cost and permit the critical-access care pharmacy to reverse and rebill each claim affected by the inability to procure the pharmaceutical product at a cost that is equal to or less than the previously challenged rate of reimbursement.

The pharmacy benefits manager shall pay or waive the cost of any transaction fee required to reverse and rebill the claim.

6.

The department of commerce and insurance shall enforce this section.

376.399.

1.

Health benefit plans beginning on or after January 1, 2027, shall comply with H.R.

7148, the Consolidated Appropriations Act, 2026.

2.

For plan years beginning on or after January 1, 2027, no contract or arrangement or renewal or extension of a contract or arrangement, entered into on or HCS HBs 1850 & 1975 11 after January 1, 2027, for services between a covered plan and a covered service provider, or between a sponsor of a covered plan and a covered service provider, through a health insurance issuer offering group health insurance coverage, a third- party administrator, an entity providing pharmacy benefit management services, or other entity, for pharmacy benefit management services, is reasonable within the meaning of this section unless such entity providing pharmacy benefit management services:

(1) Remits one hundred percent of rebates, fees, alternative discounts, and other remuneration received from any applicable entity that are related to utilization of drugs or drug spending under such health plan or health insurance coverage, to the group health plan or, in the case of a health insurance issuer offering group health insurance coverage in connection with a group health plan, to the health insurance issuer offering group health insurance coverage on behalf of the plan;

and (2) Does not enter into any contract for pharmacy benefit management services on behalf of such a plan or coverage with an applicable entity unless one hundred percent of rebates, fees, alternative discounts, and other remuneration received under such contract that are related to the utilization of drugs or drug spending under such group health plan or health insurance coverage are remitted to the group health plan or, in the case of a health insurance issuer offering group health insurance coverage in connection with a group health plan, to the health insurance issuer on behalf of the plan by the entity providing pharmacy benefit management services.

Nothing in this subsection shall be construed to affect the term of a contract or arrangement, as in effect on January 1, 2027, except that such subsection shall apply to any renewal or extension of such a contract or arrangement entered into on or after such effective date, as so described.

3.

With respect to such rebates, fees, alternative discounts, and other remuneration, the rebates, fees, alternative discounts, and other remuneration under this section shall be remitted:

(1) On a quarterly basis, to the group health plan or, in the case of a health insurance issuer offering group health insurance coverage in connection with a group health plan, to the group health insurance issuer on behalf of the plan, not later than ninety days after the end of each quarter;

or (2) In the case of an underpayment in a remittance for a prior quarter, as soon as practicable, but not later than ninety days after notice of the underpayment is first given;

HCS HBs 1850 & 1975 12 (3) Fully disclosed and enumerated to the group health plan or health insurance issuer;

and (4) Returned to the covered service provider for pharmacy benefit management services on behalf of the group health plan if any audit by a plan sponsor, issuer, or third party designated by a plan sponsor indicates that the amounts received are in excess of correct amounts after such amounts have been paid to the group health plan, in the amount of such excess.

4.

The department of commerce and insurance shall enforce this section and shall have the right to any information described in this section from any pharmacy benefits manager under investigation individually or in aggregate at the department's request.

[376.387.

1.

For purposes of this section, the following terms shall mean:

(1) "Covered person", the same meaning as such term is defined in section 376.1257;

(2) "Health benefit plan", the same meaning as such term is defined in section 376.1350;

(3) "Health carrier" or "carrier", the same meaning as such term is defined in section 376.1350;

(4) "Pharmacy", the same meaning as such term is defined in chapter 338;

(5) "Pharmacy benefits manager", the same meaning as such term is defined in section 376.388.

2.

No pharmacy benefits manager shall include a provision in a contract entered into or modified on or after August 28, 2018, with a pharmacy or pharmacist that requires a covered person to make a payment for a prescription drug at the point of sale in an amount that exceeds the lesser of:

(1) The copayment amount as required under the health benefit plan;

or (2) The amount an individual would pay for a prescription if that individual paid with cash.

3.

A pharmacy or pharmacist shall have the right to provide to a covered person information regarding the amount of the covered person's cost share for a prescription drug, the covered person's cost of an alternative drug, and the covered person's cost of the drug without adjudicating the claim through the pharmacy benefits manager.

Neither a pharmacy nor a pharmacist shall be proscribed by a pharmacy benefits manager from discussing any such information or from selling a more affordable alternative to the covered person.

4.

No pharmacy benefits manager shall, directly or indirectly, charge or hold a pharmacist or pharmacy responsible for any fee amount related to a claim that is not known at the time of the claim's adjudication, unless the amount is a result of improperly paid claims or charges for administering a health benefit plan.

HCS HBs 1850 & 1975 13 5.

This section shall not apply with respect to claims under Medicare Part D, or any other plan administered or regulated solely under federal law, and to the extent this section may be preempted under the Employee Retirement Income Security Act of 1974 for self-funded employer-sponsored health benefit plans.

6.

A pharmacy benefits manager shall notify in writing any health carrier with which it contracts if the pharmacy benefits manager has a conflict of interest, any commonality of ownership, or any other relationship, financial or otherwise, between the pharmacy benefits manager and any other health carrier with which the pharmacy benefits manager contracts.

7.

The department of commerce and insurance shall enforce this section.] ✔