S.B. 3104 - Pharmacy Benefit Managers Summary

• Transfers regulation of pharmacy benefit manager (PBM) transparency requirements from the Department of Health to the Department of Commerce and Consumer Affairs, placing oversight with the insurance commissioner.

• Requires PBMs to provide contracting pharmacies with up-to-date maximum allowable cost (MAC) lists in accessible electronic format upon request and update MAC lists at least every seven days.

• Establishes a formal appeal process allowing contracting pharmacies to challenge MAC pricing within 14 business days of claim payment, with PBM determination required within 14 business days, and requires adjustment with payment of difference if appeal is successful.

• Requires PBMs to disclose equivalent drugs available at or below the upheld MAC price when an appeal is denied, and prohibits PBMs from penalizing pharmacies for discussing cost-share information or offering lower-priced alternatives.

• Increases penalties for PBM violations to up to $10,000 per violation and allows the insurance commissioner to order corrective action and restitution.