MO SB918

Prohibits pharmacy benefit managers from automatically enrolling pharmacies, requiring participation in multiple contracts as a condition, or discriminating between in-network pharmacies based on copayments or days of supply unless the pharmacy declines to fill prescriptions at the standard network price.

Requires pharmacy benefit managers and health carriers to obtain department approval for any "switch communications" recommending patients change medications, with communications must disclose financial incentives offered to prescribers, clinical effects, cost impacts, and patient discussion rights.

Establishes that pharmacy benefit managers owe a fiduciary duty to covered entities and must notify them of any conflicts of interest, with violations punishable by fines up to $25,000.

Requires health carriers and PBMs to provide prescribers a clear process to request overrides for step therapy or fail-first protocols, which must be expeditiously granted when prescriber demonstrates clinical ineffectiveness or risk of adverse reactions based on sound clinical evidence.

Limits step therapy or fail-first protocol duration to 14 days when deemed clinically ineffective, extendable up to 21 days if clinical evidence shows the medication requires more than two weeks to provide relief.