Bill Text: AZ HB2208 | 2025 | Fifty-seventh Legislature 1st Regular | Introduced
Bill Title: Pharmacists; pharmacies; reimbursement costs; appeals
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced) 2025-02-17 - House HHS Committee action: Do Pass, voting: (9-0-2-1-0-0) [HB2208 Detail]
Download: Arizona-2025-HB2208-Introduced.html
|
REFERENCE TITLE: pharmacists; pharmacies; reimbursement costs; appeals |
|
State of Arizona House of Representatives Fifty-seventh Legislature First Regular Session 2025
|
|
HB 2208 |
|
|
|
Introduced by Representative Bliss
|
AN ACT
amending title 20, chapter 25, article 2, arizona revised statutes, by adding section 20-3335; relating to pharmacy benefit managers.
(TEXT OF BILL BEGINS ON NEXT PAGE)
Be it enacted by the Legislature of the State of Arizona:
Section 1. Title 20, chapter 25, article 2, Arizona Revised Statutes, is amended by adding section 20-3335, to read:
20-3335. Pharmacy benefit managers; prescription drugs or devices; reimbursement costs; appeals; procedures; exception; definitions
A. A pharmacy benefit manager may not reimburse a pharmacist or pharmacy that is under contract with the pharmacy benefit manager for a prescription drug or device in an amount that is less than the actual cost paid by the pharmacist or pharmacy.
B. Subsection A of this section does not apply to a pharmacy benefit manager that uses ingredient cost reimbursement methodology for a prescription drug or device that is identical to the fee-for-service methodology that is used in the state plan for medical assistance as approved by the centers for medicare and medicaid services.
C. A pharmacy benefit manager may not include a professional dispensing fee in the amount that is calculated to reimburse a pharmacy for a prescription drug or device to satisfy the requirements of subsection A of this section.
D. A pharmacy benefit manager shall pay a professional dispensing fee at a rate not less than the fee-for-service methodology used in the state plan for medical assistance as approved by the centers for medicare and medicaid services.
E. A pharmacy benefit manager shall include in the contract with each pharmacist or pharmacy a procedure that outlines how a pharmacist or pharmacy may appeal a reimbursement rate that allegedly does not comply with subsection A of this section. A pharmacist or pharmacy shall file an appeal within seven business days after the date on which the pharmacist or pharmacy was reimbursed for a prescription drug or device.
F. A pharmacy benefit manager shall file its appeal procedures with the department on a form and in a manner prescribed by the department. The department shall approve or deny a pharmacy benefit manager's appeal procedure. The appeal procedure shall include a provision that allows an agent of a pharmacist or pharmacy to submit an appeal on behalf of the pharmacist or pharmacy. A pharmacist or pharmacy may designate a pharmacy services administrative organization or other agent to file and conduct the appeal.
G. If a pharmacist or pharmacy prevails in an appeal of a reimbursement cost under this section, the pharmacy benefit manager shall complete all of the following not later than seven business days after the date the pharmacist or pharmacy prevailed on appeal:
1. Make the necessary change to the challenged reimbursement or actual cost.
2. Provide the pharmacist or pharmacy with the national drug code number for a prescription drug, if the appeal was based on a prescription drug.
3. Allow the pharmacist or pharmacy to reverse and rebill the claim.
4. Reimburse the pharmacist's or pharmacy's actual cost for the prescription drug or device.
5. Apply the findings of the appeal to the reimbursement rate and actual cost for the prescription drug or device to other similarly situated pharmacists and pharmacies.
H. If a pharmacy benefit manager prevails in an appeal of a reimbursement cost under this section and the prescription drug or device that is the subject of the appeal is available at a cost that is equal to or less than the challenged reimbursement cost, the pharmacy benefit manager shall provide to the pharmacist or pharmacy both of the following not later than seven business days after the pharmacy benefit manager prevailed on appeal:
1. The name of the national or regional pharmaceutical wholesaler that does business in this state and that has the prescription drug or device in stock at a price that is equal to or less than the challenged reimbursement cost.
2. The national drug code number for the prescription drug or the unique identifier for the device, as applicable.
I. If the pharmacy benefit manager does not comply with subsection A of this section, the pharmacy benefit manager shall:
1. Adjust the challenged reimbursement cost to an amount that is equal to or greater than the pharmacist's or pharmacy's actual cost.
2. Allow the pharmacist or pharmacy to reverse and rebill each claim that is affected by the inability to obtain the prescription drug or device at a cost that is equal to or less than the challenged reimbursement.
J. This SECTION does not apply to health and accident insurance coverage that is procured by the department of administration pursuant to section 38-651.
K. For the purposes of this section:
1. "Similarly situated pharmacists or pharmacies" means pharmacists or pharmacies that met all of the following:
(a) Are under contract with a pharmacy benefit manager.
(b) Purchase a prescription drug or device that is the subject of an appeal of a reimbursement cost that allegedly does not comply with subsection A of this section from the same pharmaceutical wholesaler as the pharmacist or pharmacy that prevailed in the appeal.
(c) To whom the pharmacy benefit manager applies the challenged reimbursement rate or actual cost for the prescription drug or device.
2. "State plan" means the Arizona health care cost containment system.
Sec. 2. Applicability
Section 20-3335, Arizona Revised Statutes, as added by this act, applies to contracts that are entered into, amended, extended or renewed on or after December 31, 2025.
