State Policy Options and Pharmacy Benefit Managers (PBMs)

3/23/2022

prescription drugs

Prescription drugs can dramatically improve one’s quality of life, with some therapies being the only thing separating a person from death – but the price for this innovation can come at a steep price. The Centers for Medicare & Medicaid Services (CMS) reports that consumer purchases of prescription drugs totaled $369.7 billion in 2019. Consumers filled over 3.7 billion retail prescriptions in 2019, according to the Kaiser Family Foundation, although the Pharmaceutical Research and Manufacturers of America (PhRMA) estimates that number to be much higher. The majority—approximately three-quarters of prescriptions—are processed by a pharmacy benefit manager (PBM). Historically, state laws focused on the role of other actors in the supply chain, but more attention is now being drawn to the role of PBMs.

What are Pharmacy Benefit Managers (PBMs) and What is Their Role?

Pharmacy benefit managers (PBMs) are paid third-party administrators of prescription drug coverage for insurers and employers. They provide a wide variety of services including developing and maintaining formularies, processing claims, and negotiating discounts and rebates between payers and manufacturers. PBMs manage plans for millions of Americans who have health insurance from a variety of sponsors including commercial health plans, self-insured employer plans, Medicare Part D plans, state government employee plans, and Medicaid managed care organization (MCO) plans.

State Actions

Click on any provision next to the map to see corresponding states. You can also click on any state for state-specific statutes below.

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Alabama

Provision 

Statute

Cost Disclosure/Gag Clause

Ala. Code §27-45A-10 (2021)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

 

Network Adequacy

Ala. Code §27-45-3 (1988)

Patient Steering

Ala. Code §27-45A-8 (2021)

Pharmacy Auditing Standards/Appeals Process

Ala. Code §34-23-184 (2018)

Pharmacy Reimbursement/Claw Backs

Ala. Code §27-45A-10 (2021)

Registration

Licensure

Ala. Code §27-45A-4 (2021)

Regulatory Agency/Enforcement

Ala. Code §27-45A-4 (2021)

Ala. Code §27-45A-5 (2021)

Reporting/Transparency Requirements

Ala. Code §27-45A-9 (2021)

Spread Pricing

Ala. Code §27-45A-9 (2021)

Utilization Management Tools

 

Other

 

Alaska

Provision 

Statute 

Cost-Disclosure/Gag-Clause 

Alaska Stat. §08.80.297  

Fiduciary 

 

Maximum Allowable Cost (MAC) Lists 

Alaska Stat. §145.400 (Medicaid) (AAC)  

Alaska Stat. §21.27.945 

Alaska Stat. §21.27.950 

Network Adequacy 

Alaska Stat. §21.27.945 

Alaska Stat. §21.27.950  

Patient Steering 

 

Pharmacy Auditing Standards/Appeals Process 

Alaska Stat. §21.27.910 

Alaska Stat. §21.27.930 

Alaska Stat. §21.27.950 

Pharmacy Reimbursement/Claw Backs 

 

Alaska Stat. §21.27.915 

Alaska Stat. §21.27.920 

Registration/Licensure 

Alaska Stat. §21.27.901 

Regulatory Agency/Enforcement 

Alaska Stat. §08.80.030 

Reporting/Transparency Requirements 

Alaska Stat. §21.27.945 

Spread Pricing 

 

Utilization Management Tools 

 

Other 

 

Arizona

Provision

Statute

Cost Disclosure/Gag Clause

Ariz. Rev. Stat. Ann. §44-1752

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

Ariz. Rev. Stat. Ann. §20-3331

Network Adequacy

Ariz. Rev. Stat. Ann. §44-1754

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

Ariz. Rev. Stat. Ann. §20-3332

Pharmacy Auditing Standards

Appeals Process

Ariz. Rev. Stat. Ann. §20-3322

Ariz. Rev. Stat. Ann. §20-3323

Registration/Licensure

 

Regulatory Agency/Enforcement

 

Reporting/Transparency Requirements

 

Spread Pricing

 

Utilization Management Tools

Ariz. Rev. Stat. Ann. §20-3405 (Prior Authorization)

Ariz. Rev. Stat. Ann. §20-3406 (Uniform Prior Authorization)

Ariz. Rev. Stat. Ann. §20-3653 (Step-Therapy)

Other

 

Arkansas

Provision

Statute

Cost Disclosure/Gag Clause

Ark. Stat. Ann. §23-92-507 (2019)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

Ark. Stat. Ann. §17-92-507 (2019)

Network Adequacy

Ark. Stat. Ann. §23-92-505 (2021)

Patient Steering

 

Pharmacy Auditing Standards/Appeals Process

Ark. Stat. Ann. §17-92-1201 (2021)

Pharmacy Reimbursement/Claw Backs

Ark. Stat. Ann. §17-92-507 (2019)

Ark. Stat. Ann. §23-92-506 (2021)

Registration/Licensure

Ark. Stat. Ann. §23-92-504 (2018)

Regulatory Agency/Enforcement

Ark. Stat. Ann. §23-92-508 (2018)

Ark. Stat. Ann. §23-92-509 (2021)

Reporting/Transparency Requirements

Ark. Stat. Ann. §23-92-505 (2021)

Spread Pricing

Ark. Stat. Ann. §23-92-505 (2021)

Utilization Management Tools

Ark. Stat. Ann. §23-99-1114 (2021) (Step-Therapy)

Ark. Stat. Ann. §23-79-2101 (2021) (Step-Therapy)

Other

Ark. Stat. Ann. §23-92-601—23-92-606 (2021) (340B)

California

Provision

Statute

Cost Disclosure/Gag Clause

Cal. B.P.C. Code §4441 (2018)

Fiduciary

Cal. H.S.C. Code §1385.004 (2018)

Maximum Allowable Cost (MAC) Lists

Cal. B.P.C. Code §4440 (2015)

Network Adequacy

 

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

Cal. B.P.C. Code §4438 (2012)

Pharmacy Auditing Standards

Appeals Process

Cal. B.P.C. Code §4433 - 4438 (2012)

Registration/Licensure

Cal. H.S.C. Code §1385.0041385.005 (2018)

Regulatory Agency/Enforcement

Cal. B.P.C. Code §4439 (2012)

Cal. H.S.C. Code §1385.002 (2018)

Cal. H.S.C. Code §1385.006 (2018)

Reporting/Transparency Requirements

Cal. B.P.C. Code §4441 (2018)

Spread Pricing

 

Utilization Management Tools

 

Other

 

Colorado

Provision

Statute

Cost Disclosure/Gag Clause

Colo. Rev. Stat. §10-16-122.7 (2018)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

Colo. Rev. Stat. §25-37-103.5 (2015)

Network Adequacy

Colo. Rev. Stat. §24-51-1202 (2010)

Colo. Rev. Stat. §10-16-122 (2021)

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

Colo. Rev. Stat. §10-16-122.3 (2021)

Pharmacy Auditing Standards

Appeals Process

Colo. Rev. Stat. §10-16-122.5 (2021)

Registration/Licensure

 

Regulatory Agency/Enforcement

 

Reporting/Transparency Requirements

 

Spread Pricing

 

Utilization Management Tools

Colo. Rev. Stat. §10-16-124.5 (2019) (Prior Authorization)

Other

Colo. Rev. Stat. §24-50-1204 (2021) (Reverse Auction)

Connecticut

Provision

Statute

Cost Disclosure/Gag Clause

Conn. Gen. Stat. §38a-477cc (2018)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

 

Network Adequacy

 

Patient Steering

 

Pharmacy Reimbursement/

Clawbacks

Conn. Gen. Stat. §38a-477cc (2018)

Pharmacy Auditing Standards

Appeals Process

Conn. Gen. Stat. §38a-479iii (2008)

Registration/Licensure

Conn. Gen. Stat. §38a-479bbb (2008)

Regulatory Agency/Enforcement

Conn. Gen. Stat. §38a-479ccc-hhh (2008)

Reporting/Transparency Requirements

Conn. Gen. Stat. §.38a-479ppp (2020)

Spread Pricing

 

Utilization Management Tools

 

Other

 

Florida

Provision

Statute

Cost Disclosure/Gag Clause

Fla. Stat. §465.0244 (2021)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

Fla. Stat. §627.64741 (2021)

Network Adequacy

 

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

 

Pharmacy Auditing Standards

Appeals Process

Fla. Stat. §465.1885 (2021)

Registration/Licensure

Fla. Stat. §624.490 (2021)

Regulatory Agency/Enforcement

 

Reporting/Transparency Requirements

 

Spread Pricing

 

Utilization Management Tools

Fla. Stat. §627.42392 (2021) (Prior Authorization)

Other

 

Georgia

Provision

Statute

Cost Disclosure/Gag Clause

Ga. Code Ann. §33-64-11 (2021)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

Ga. Code Ann. §33-64-9 (2016)

Network Adequacy

Ga. Code Ann. §33-64-10 (2021)

Patient Steering

Ga. Code Ann. §26-4-119 (2021)

Ga. Code Ann. § 33-64-11 (2021)

Ga. Code Ann. §33-64-12 (2021)

Pharmacy Reimbursement

Clawbacks

Ga. Code Ann. §33-64-9.1 (2021)

Ga. Code Ann. §33-64-11 (2021)

Pharmacy Auditing Standards

Appeals Process

Ga. Code Ann. §26-4-118 (2021)

Ga. Code Ann. §33-64-5 (2011)

Registration/Licensure

Ga. Code Ann. §33-64-2 (2021)

Regulatory Agency/Enforcement

Ga. Code Ann. §33-64-7 (2021)

Reporting/Transparency Requirements

Ga. Code Ann. §33-64-10 (2021)

Spread Pricing

Ga. Code Ann. §33-64-10 (2021)

Utilization Management Tools

Ga. Code. Ann. §33-64-8 (2012) (Prior Authorization)

Other

 

Hawaii

Provision

Statute

Cost Disclosure/Gag Clause

 

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

Hawaii Rev. Stat. §328-106 (2015)

Network Adequacy

Hawaii Rev. Stat. §431R-2 (2013)

Hawaii Rev. Stat. §431R-3 (2013)

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

 

Pharmacy Auditing Standards

Appeals Process

 

Registration/Licensure

Hawaii Rev. Stat. §431S-3 (2021)

 

Regulatory Agency/Enforcement

Hawaii Rev. Stat. §431R-5 (2016)

Hawaii Rev. Stat. §431R-4 (2013)

Hawaii Rev. Stat. §431R-7 (2013)

Reporting/Transparency Requirements

Hawaii Rev. Stat. §431R-4 (2013)

Spread Pricing

 

Utilization Management Tools

 

Other

 

Idaho

Provision

Statute

Cost Disclosure/Gag Clause

Idaho Code §41-349 (2020)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

Idaho Code §41-349 (2020)

Network Adequacy

 

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

 

Pharmacy Auditing Standards

Appeals Process

 

Registration/Licensure

Idaho Code §41-349 (2020)

Regulatory Agency/Enforcement

 

Reporting/Transparency Requirements

 

Spread Pricing

 

Utilization Management Tools

 

Other

 

Illinois

Provision

Statute

Cost Disclosure/Gag Clause

Ill. Rev. Stat. ch. 215 §5/513b1

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

Ill. Rev. Stat. ch. 215 §5/513b1

Network Adequacy

 

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

Ill. Rev. Stat. ch. 215 §5/513b1

Pharmacy Auditing Standards

Appeals Process

Ill. Rev. Stat. ch. 215 §5/513b1

Registration/Licensure

Ill. Rev. Stat. ch. 215 §5/513b2

Regulatory Agency/Enforcement

Ill. Rev. Stat. ch. 215 §5/513b3

Ill. Rev. Stat. ch. 215 §5/513b4

Ill. Rev. Stat. ch. 215 §5/513b5

Reporting/Transparency Requirements

 

Spread Pricing

 

Utilization Management Tools

 

Other

 

Indiana

Provision

Statute

Cost Disclosure/Gag Clause

Ind. Code §10-8-20 (2020)

Fiduciary

Ind. Code §27-1-25-6 (2021)

Maximum Allowable Cost (MAC) Lists

Ind. Code §27-1-24.5-23 (2021)

Network Adequacy

Ind. Code §27-1-24.5-19 (2021)

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

Ind. Code §27-1-24.5-19 (2021)

Ind. Code §27-1-24.5-27.5 (2021)

Pharmacy Auditing Standards

Appeals Process

Ind. Code §27-1-24.5-22 (2021)

Registration/Licensure

Ind. Code §27-1-24.5-18 (2020)

Regulatory Agency/Enforcement

Ind. Code §27-1-24.5-20 (2020)

Reporting/Transparency Requirements

Ind. Code §27-1-24.5-21 (2020)

Ind. Code §27-1-24.5-22.5 (2020)

Spread Pricing

 

Utilization Management Tools

 

Other

Ind. Code §27-1-24.5-19.5 (2021) (340B)

Iowa

Provision

Statute

Cost Disclosure/Gag Clause

Iowa Code §510B.10 (2018)

Fiduciary

Iowa Code §510B.4 (2008)

Maximum Allowable Cost (MAC) Lists

Iowa Code §510B.8 (2020)

Network Adequacy

Iowa Code §510B.7 (2008)

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

 

Pharmacy Auditing Standards

Appeals Process

Iowa Code §510B.8 (2020)

 

Registration/Licensure

Iowa Code §510B.2 (2008)

Regulatory Agency/Enforcement

Iowa Code §510C.2 (2020)

Iowa Code §510B.3 (2015)

Reporting/Transparency Requirements

Iowa Code §510C.2 (2020)

Spread Pricing

 

Utilization Management Tools

Iowa Code §510B.9 (2014)

Other

 

Kansas

Provision

Stat

Cost Disclosure/Gag Clause

Kan. Stat. Ann. §40-3831 (2018)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

Kan. Stat. Ann. §40-3830 (2016)

Network Adequacy

 

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

Kan. Stat. Ann. §40-3830 (2016)

Pharmacy Auditing Standards

Appeals Process

Kan. Stat. Ann. §40-3830 (2016)

Kan. Stat. Ann. §65-16,123 (2011)

Kan. Stat. Ann. §65-16,124 (2011)

Registration/Licensure

Kan. Stat. Ann. §40-3823 (2006)

Kan. Stat. Ann §40-3824 (2006)

Regulatory Agency/Enforcement

Kan. Stat. Ann. §40-3830 (2016) 40-3825 (2006)

Reporting/Transparency Requirements

 

Spread Pricing

 

Utilization Management Tools

 

Other

 

Kentucky

Provision

Statute

Cost Disclosure/Gag Clause

Ky. Rev. Stat. §304.17A-164 (2022)

Fiduciary

Ky. Rev. Stat. §205.5512 4(c)(1) (2020) (Medicaid)

Maximum Allowable Cost (MAC) Lists

Ky. Rev. Stat. §304.17A-162 (2016)

Network Adequacy

Ky. Rev. Stat. §205.5514 4(d) (2020) (Medicaid)

Patient Steering

Ky. Rev. Stat. §205.5512 4(c)(4biii, iv, v) (2020) (Medicaid)

Pharmacy Reimbursement

Clawbacks

Ky. Rev. Stat. §205.5512 4(c)(4bi, ii) (2020)

(Medicaid)

Pharmacy Auditing Standards

Appeals Process

Ky. Rev. Stat. §304.17A-741 (2012)

Ky. Rev. Stat. §304.17A-743 (2009)

Registration/Licensure

Ky. Rev. Stat. §304.9-053 (2016).

Regulatory Agency/Enforcement

Ky. Rev. Stat. §304.9-054 (2016)

Ky. Rev. Stat. §205.5518 (3) (2020) (Medicaid)

Ky. Rev. Stat. §304.9-440 (2021)

Reporting/Transparency Requirements

Ky. Rev. Stat. §205.647 (2020) (Medicaid)

Spread Pricing

Ky. Rev. Stat. §205.5512 4(c)(3a)(4a) (2020) (Medicaid)

Utilization Management Tools

Ky. Rev. Stat. §304.17A-163 (2012) (Step-Therapy)

Other

 

Louisiana

Provision

Statute

Cost Disclosure/Gag Clause

La. Rev. Stat. Ann. §22:1657 (West 2020)

La. Rev. Stat. Ann. §37:1219 (West 2018)  

Fiduciary

La. Rev. Stat. Ann. §40:2870 (West 2020)  

Maximum Allowable Cost (MAC) Lists

La. Rev. Stat. Ann. §40:2870 (West 2020) 

Network Adequacy

La. Rev. Stat. Ann. §39:1648 (West 2021) (Medicaid)

La. Rev. Stat. Ann. §40:2870 (West 2020)

Patient Steering

La. Rev. Stat. Ann. §40:2870 (West 2020)

Pharmacy Reimbursement

Clawbacks

La. Rev. Stat. Ann. §22:1860.3 (West 2018)

La. Rev. Stat. Ann. §40:2870 (West 2020)

Pharmacy Auditing Standards

Appeals Process

La. Rev. Stat. Ann. §22:1865 (West 2014)

Registration/Licensure

La. Rev. Stat. Ann. §22:1657 (West 2020)

La. Rev. Stat. Ann. §40:2865 (West 2019)

La. Rev. Stat. Ann. §40:2870 (West 2020)

Regulatory Agency/Enforcement

La. Rev. Stat. Ann. §22:1657.1 (West 2020)

La. Rev. Stat. Ann. §37:1257 (West 2019)

La. Rev. Stat. Ann. §40:2868 (West 2020)

La. Rev. Stat. Ann. §40:2871 (West 2020)

Reporting/Transparency Requirements

La. Rev. Stat. Ann. §22:1657.1 (West 2020)

La. Rev. Stat. Ann. §40:1253.2 (West 2018)

Spread Pricing

La. Rev. Stat. Ann. §22:1867 (West 2020)

La. Rev. Stat. Ann. §39:1648 (West 2018)

La. Rev. Stat. Ann. §40:2870 (West 2020)

Utilization Management Tools

La. Rev. Stat. Ann. §22:1053 (West 2020) (Step Therapy)

La. Rev. Stat. Ann. §22:1006.1 (West 2020) (Prior Authorization)

La. Rev. Stat. Ann. §40:2870 (West 2020) (Step Therapy) (Prior Authorization)

Other

La. Rev. Stat. Ann. §39:1600.1 (West 2021) (Reverse Auction)

La. Rev. Stat. Ann. §40:2869 (West 2019) (Pharmacy Benefit Manager Monitoring Council)

Maryland

Provision

Statute

Cost Disclosure/Gag Clause

Md. [Insurance] Code Ann. §15–1611 (2022)

Fiduciary

Md. [Insurance] Code Ann. §15–1642 (2019)

Maximum Allowable Cost (MAC) Lists

Md. [Insurance] Code Ann. §15–1628.1 (2019)

Network Adequacy

Md. [Insurance] Code Ann. §15–1611.1 (2022)

Md. [Insurance] Code Ann. §15-1628 (2022)

Patient Steering

Md. [Insurance] Code Ann. §15–1611.1 (2022)

Pharmacy Reimbursement

Clawbacks

Md. [Insurance] Code Ann. §15–1612 (2022)

Md. [Insurance] Code Ann. §15–1628.3 (2022)

Md. [Insurance] Code Ann. §15–1631 (2019)

Pharmacy Auditing Standards

Appeals Process

Md. [Insurance] Code Ann. §15–1628.1 (2019)

Md. [Insurance] Code Ann. §15–1628.2 (2021)

Md. [Insurance] Code Ann. §15–1629 (2022)

Registration/Licensure

Md. [Insurance] Code Ann. §15–1604 (2018)

Regulatory Agency/Enforcement

Md. [Insurance] Code Ann. §15–1604 (2018)

Md. [Insurance] Code Ann. §15–1607 (2018)

Md. [Insurance] Code Ann. §15–1609 (2008)

Reporting/Transparency Requirements

Md. [Insurance] Code Ann. §15–1623 (2008)

Md. [Insurance] Code Ann. §15–1624 (2008)

Spread Pricing

 

Utilization Management Tools

Md. [Insurance] Code Ann. §15–1633.1 (2008) (Non-Medical Switching)

Md. [Insurance] Code Ann. §15–1634 (2008) (Non-Medical Switching)

Md. [Insurance] Code Ann. §15–1635 (2008) (Non-Medical Switching)

Md. [Insurance] Code Ann. §15–1636 (2008) (Non-Medical Switching)

Other

Md. [State Personnel & Pensions] Code Ann. §2–502.2 (2020) (Reverse Auction)

Massachusetts

Provision

Statute

Cost Disclosure/Gag Clause

 

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

 

Network Adequacy

 

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

 

Pharmacy Auditing Standards

Appeals Process

Mass. Gen. Laws Ann. ch. 175, §226 (West 2015)

Registration/Licensure

 

Regulatory Agency/Enforcement

 

Reporting/Transparency Requirements

Mass. Gen. Laws Ann. ch.176O, §21 (2018)

Spread Pricing

 

Utilization Management Tools

 

Other

 

Michigan

Provision

Statute

Cost Disclosure/Gag Clause

 

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

 

Network Adequacy

 

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

 

Pharmacy Auditing Standards

Appeals Process

 

Registration/Licensure

Mich. Comp. Laws Ann. §550.910 (1985)

Regulatory Agency/Enforcement

Mich. Comp. Laws Ann. §550.950 (1985)

Reporting/Transparency Requirements

 

Spread Pricing

 

Utilization Management Tools

 

Other

 

Minnesota

Provision

Statute

Cost Disclosure/Gag Clause

Minn. Stat. Ann. §62W.11 (2021)

Minn. Stat. Ann. §151.214 (2019)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

Minn. Stat. Ann. §62W.08 (2019)

Network Adequacy

Minn. Stat. Ann. §62W.05 (2019)

Patient Steering

Minn. Stat. Ann. §62W.07 (2019)

Pharmacy Reimbursement

Clawbacks

Minn. Stat. Ann. §62W.12 (2019)

Minn. Stat. Ann. §62W.13 (2019)

Pharmacy Auditing Standards

Appeals Process

Minn. Stat. Ann. §62W.09 (2019)

Registration/Licensure

Minn. Stat. Ann. §62W.03 (2019)

Regulatory Agency/Enforcement

Minn. Stat. Ann. §62W.03 (2019)

Reporting/Transparency Requirements

Minn. Stat. Ann. §62W.06 (2019)

Spread Pricing

Minn. Stat. Ann. §62W.06 (2019)

Utilization Management Tools

Minn. Stat. Ann. §62W.075 (2019) (Non-Medical Switching)

Other

 

Mississippi

Provision

Statute

Cost Disclosure/Gag Clause

Miss. Code Ann. §73-21-205 (2018)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

Miss. Code Ann. §73-21-156 (2021)

Network Adequacy

Miss. Code Ann. §73-21-161 (2021)

Patient Steering

Miss. Code Ann. §73-21-161 (2021)

Pharmacy Reimbursement

Clawbacks

Miss. Code Ann. §73-21-155 (2021)

Pharmacy Auditing Standards

Appeals Process

Miss. Code Ann. §73-21-183 (2012)

Miss. Code Ann. §73-21-185 (2012)

Registration/Licensure

Miss. Code Ann. §73-21-157 (2021)

Regulatory Agency/Enforcement

Miss. Code Ann. §73-21-155 (2021)

Miss. Code Ann. §73-21-159 (2021)

Miss. Code Ann. §73-21-163 (2021)

Miss. Code Ann. §73-21-191 (2012)

Reporting/Transparency Requirements

 

Spread Pricing

 

Utilization Management Tools

 

Other

 

Missouri

Provision

Statute

Cost Disclosure/Gag Clause

Mo. Rev. Stat. §376.387 (2020)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

Mo. Rev. Stat. §376.388 (2016)

Network Adequacy

 

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

Mo. Rev. Stat. §376.387 (2020)

Pharmacy Auditing Standards

Appeals Process

Mo. Rev. Stat. §338.600 (2008)

Registration/Licensure

Mo. Rev. Stat. §376.393 (2020)

Regulatory Agency/Enforcement

Mo. Rev. Stat. §376.387 (2020)

Mo. Rev. Stat. §376.393 (2020)

Reporting/Transparency Requirements

 

Spread Pricing

 

Utilization Management Tools

Mo. Rev. Stat. §376.392 (2008) (Formulary Deletions)

Other

 

Montana

Provision

Statute

Cost Disclosure/Gag Clause

Mont. Code Ann. §33-22-174 (2022)

Mont. Code Ann. §33-2-2404 (2022)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

Mont. Code Ann. §33-22-171-173 (2015-2019)

Network Adequacy

Mont. Code Ann. §33-2-2409 (2022)

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

Mont. Code Ann. §33-22-175 (2020)

Mont. Code Ann. §33-22-176 (2020)

Pharmacy Auditing Standards

Appeals Process

Mont. Code Ann. §33-22-177 (2020)

Registration/Licensure

Mont. Code Ann. §33-2-2403 (2022)

Regulatory Agency/Enforcement

Mont. Code Ann. §33-2-2403 (2022)

Mont. Code Ann. §33-2-2411 (2022)

Reporting/Transparency Requirements

Mont. Code Ann. §33-2-2406 (2022)

Mont. Code Ann. §33-2-2407 (2022)

Spread Pricing

 

Utilization Management Tools

 

Other

Mont. Code Ann. §33-2-2410 (2021) (340B)

Nebraska

Provision

Statute

Cost Disclosure/Gag Clause

Neb. Rev. Stat. §71-2484 (2019)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

 

Network Adequacy

 

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

 

Pharmacy Auditing Standards

Appeals Process

 

Registration/Licensure

 

Regulatory Agency/Enforcement

 

Reporting/Transparency Requirements

 

Spread Pricing

 

Utilization Management Tools

Neb. Rev. Stat. §44-7, 111 (2021) to Neb. Rev. Stat. §44-7, 117 (2021) (Step Therapy)

Other

 

Nevada

Provision

Statute

Cost Disclosure/Gag Clause

Nev. Rev. Stat. §683A.179(1)a (2022)

Fiduciary

Nev. Rev. Stat. §683A.178 (2020)

Maximum Allowable Cost (MAC) Lists

 

Network Adequacy

 

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

 

Pharmacy Auditing Standards

Appeals Process

 

Registration/Licensure

 

Regulatory Agency/Enforcement

 

Reporting/Transparency Requirements

Nev. Rev. Stat. §439B.645 (2021)

Spread Pricing

 

Utilization Management Tools

 

Other

 

New Hampshire

Provision

Statute

Cost Disclosure/Gag Clause

N.H. Rev. Stat. Ann. §402-N:4 (2020)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

N.H. Rev. Stat. Ann. §402-N:3 (2020)

Network Adequacy

N.H. Rev. Stat. Ann. §402-N:4-a (2021)

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

N.H. Rev. Stat. Ann. §402-N:4 (2020)

Pharmacy Auditing Standards

Appeals Process

 

Registration/Licensure

N.H. Rev. Stat. Ann. §402-N:2 (2020)

Regulatory Agency/Enforcement

N.H. Rev. Stat. Ann. §402-N:2 (2020)

N.H. Rev. Stat. Ann. §402-N:7 (2020)

N.H. Rev. Stat. Ann. §402-N:5 (2021)

N.H. Rev. Stat. Ann. §402-N:2 (2020)

Reporting/Transparency Requirements

N.H. Rev. Stat. Ann. §402-N:6 (2020)

Spread Pricing

 

Utilization Management Tools

 

Other

 

New Jersey

Provision

Statute

Cost Disclosure/Gag Clause

N.J. Stat. Ann. §17B:27F-6(1)b

Fiduciary

N.J. Admin. Code § 11:23-3.4

Maximum Allowable Cost (MAC) Lists

N.J. Admin. Code §11:4-62.3

N.J. Stat. Ann. §17B:27F-2

N.J. Stat. Ann. §17B:27F-3

Network Adequacy

N.J. Stat. Ann. §17B:26-2.1i

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

N.J. Stat. Ann. §17B:27F-7

N.J. Stat. Ann. §17B-27F-6(1)a

Pharmacy Auditing Standards

Appeals Process

N.J. Admin. Code §11:4-62.4

N.J. Stat. Ann. §17B:27F-4

Registration/Licensure

N.J. Admin. Code §11:23-2.1—11:23.6

N.J. Stat. Ann. §17B:27B-2

Regulatory Agency/Enforcement

N.J. Admin. Code §11:4-62.5

N.J. Admin. Code §11:4-62.6

N.J. Admin. Code §11:23-3.2

N.J. Admin. Code §11:23-3.8

N.J. Admin. Code §11:23-4.1—4.3

N.J. Stat. Ann. §17B:27F-5

Reporting/Transparency Requirements

N.J. Rev. Stat. §30:4D-7ee

Spread Pricing

 

Utilization Management Tools

 

Other

N.J. Admin. Code §5:34-5.6 (Reverse Auction)

New Mexico

Provision

Statute

Cost Disclosure/Gag Clause

N.M. Stat. Ann. §59A-61-5E(3)(b) (2019)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

N.M. Stat. Ann. §59A-61-4 (2019)

Network Adequacy

N.M. Stat. Ann. §59A-61-5(H) (2019)

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

N.M. Stat. Ann. §59A-61-4(B) (2019)

N.M. Stat. Ann. §59A-61-7 (2019)

Pharmacy Auditing Standards

Appeals Process

N.M. Stat. Ann. §59A-61-4(D)(4) (2019)

Registration/Licensure

N.M. Stat. Ann. §59A-61-3 (2019)

Regulatory Agency/Enforcement

N.M. Stat. Ann. §59A-61-3 (2019)

Reporting/Transparency Requirements

 

Spread Pricing

 

Utilization Management Tools

N.M. Stat. Ann. §59A-22B-4 (2019) (Uniform Prior Authorization)

N.M. Stat. Ann. §59A-22B-5 (2019) (Prior Authorization)

N.M. Stat. Ann. §59A-22-53.1 (2018) (Step Therapy)

 

Other

 

North Carolina

Provision

Statute

Cost Disclosure/Gag Clause

N.C. Gen. Stat. §58-56A-3 (2021)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

N.C. Gen. Stat. §58-56A-5 (2021)

Network Adequacy

N.C. Gen. Stat. §58-51-37 (2021)

N.C. Gen. Stat. §58-56A-15 (2021)

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

N.C. Gen. Stat. §58-56A-4 (2021)

Pharmacy Auditing Standards

Appeals Process

N.C. Gen. Stat. §90-85.50 (2013)

Registration/Licensure

N.C. Gen. Stat. §58‑56A‑2 (2021)

Regulatory Agency/Enforcement

N.C. Gen. Stat. §58-56A-10 (2021)

N.C. Gen. Stat. §58-56A-25 (2021)

N.C. Gen. Stat. §58-56A-30 (2021)

Reporting/Transparency Requirements

 

Spread Pricing

 

Utilization Management Tools

N.C. Gen. Stat. §58-3-221 (2020) (Exception Process)

Other

N.C. Gen. Stat. §58-51-37 (2021) (340B)

N.C. Gen. Stat. §58-56A-50 (2021) (340B)

North Dakota

Provision

Statute

Cost Disclosure/Gag Clause

N.D. Cent. Code §19-02.1-16.1(7) (2017)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

N.D. Cent. Code §19-02.1-14.2 (2013)

Network Adequacy

N.D. Cent. Code §19-02.1-16.2 (2017)

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

N.D. Cent. Code §19-02.1-16.1 (2017)

Pharmacy Auditing Standards

Appeals Process

N.D. Cent. Code §19-03.6-02 (2011)

N.D. Cent. Code §19-03.6-03 (2011)

Registration/Licensure

N.D. Cent. Code §26.1-27.1-02 (2005)

Regulatory Agency/Enforcement

N.D. Cent. Code §26.1-27.1-07 (2005)

N.D. Cent. Code §26.1-36.10-06 (2021)N.D. Cent. Code §26.1-36.10-08 (2021)

Reporting/Transparency Requirements

N.D. Cent. Code §26.1-36.10.03 (2021)

Spread Pricing

 

Utilization Management Tools

N.D. Cent. Code §19-02.1-16.3 (2019) (Step Therapy)

Other

N.D. Cent. Code §19-02.1-16.5 (2021) (340B)

Oklahoma

Provision

Statute

Cost Disclosure/Gag Clause

Okla. Stat. Ann. tit. 36, 6962(C)(1) (2019)

Okla. Stat. Ann. tit. 59, §359 (2021)

Fiduciary

Okla. Stat. Ann. tit. 36, §1445 (2021)

Maximum Allowable Cost (MAC) Lists

Okla. Stat. Ann. tit. 59, §360 (2021)

Network Adequacy

Okla. Stat. Ann. tit. 36, §6961 (2019)

Okla. Stat. Ann. tit. 36, §6963(B)(4)(C) (2019)

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

Okla. Stat. Ann. tit. 36, §6962(B) (2019)

 

Pharmacy Auditing Standards

Appeals Process

Okla. Stat. Ann. tit. 59, § 356.1-.356.5 (2021)

Registration/Licensure

Okla. Stat. Ann. tit. 59, §358 (2021)

Regulatory Agency/Enforcement

Okla. Stat. Ann. tit. 36, § 6965 (2021)

Okla. Stat. Ann. tit. 36 § 6966 (2021)

Okla. Stat. Ann. tit. 59, §358 (2021)

Reporting/Transparency Requirements

 

Spread Pricing

 

Utilization Management Tools

 

Other

 

Oregon

Provision

Statute

Cost Disclosure/Gag Clause

Or. Rev. Stat. §735.536(2)(f) (2019)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

Or. Rev. Stat. §735.534 (2019)

Network Adequacy

 

Patient Steering

Or. Rev. Stat. §735.536 (2019)

Pharmacy Reimbursement

Clawbacks

Or. Rev. Stat. §735.536 (2019)

Pharmacy Auditing Standards

Appeals Process

Or. Rev. Stat. §735.534(4) (2019)

Or. Rev. Stat. §735.542 (2013)

Registration/Licensure

Or. Rev. Stat. §735.532 (2017)

Regulatory Agency/Enforcement

Or. Rev. Stat. §735.532 (2017)

Or. Rev. Stat. §735.533 (2017)

Or. Rev. Stat. §735.552 (2013)

Reporting/Transparency Requirements

 

Spread Pricing

 

Utilization Management Tools

Or. Rev. Stat. §743B.420 (2021) (Prior Authorization)

Or. Rev. Stat. §743B.422 (2021) (Prior Authorization)

Or. Rev. Stat. §743B.423 (2021) (Prior Authorization)

Or. Rev. Stat. §743B.425 (2021) (Prior Authorization)

Or. Rev. Stat. §743B.602 (2021) (Step-Therapy)

Or. Rev. Stat. §414.772 (2019) (Step-Therapy)

Other

 

Pennsylvania

Provision

Statute

Cost Disclosure/Gag Clause

 Pa. Act 67 §3 (2020)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

Pa. Act 169 Ch. 7 §701 (2016)

Network Adequacy

 

Patient Steering

Pa. Act 120 Ch. 7 §449(2g) (2020)

Pharmacy Reimbursement

Clawbacks

Pa. Act 120 Ch. 7 §449 (2020)

Pa. Act 169 Ch. 7 §701 (2016)

Pharmacy Auditing Standards

Appeals Process

Pa. Act 120 Ch. 7 §449 (2020)

Pa. Act 169 Ch. 3 §301 (2016)

Pa. Act 169 Ch. 7 §701 (2016)

Registration/Licensure

Pa. Act 169 Ch. 5 §501 (2016)

Regulatory Agency/Enforcement

Pa. Act 169 Ch. 9 §901 (2016)

Reporting/Transparency Requirements

Pa. Act 120 Ch. 9 §449 (2020)

Spread Pricing

Pa. Act 120 Ch. 9 §449 (2020)

Utilization Management Tools

 

Other

 

Rhode Island

Provision

Statute

Cost-Disclosure/Gag-Clause

R.I. Gen. Laws §27-20.8-4 (2021)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

R.I. Gen. Laws § 27-18-33.2 (2016)

R.I. Gen. Laws § 27-41-38.2 (2016)

Network Adequacy

R.I. Gen. Laws §27-29.1-3 (2004)

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

 

Pharmacy Auditing Standards

Appeals Process

R.I. Gen. Laws §5-19.1-35 (2019)

Registration/Licensure

R.I. Gen. Laws §27-20.7-12 (2001)

Regulatory Agency/Enforcement

R.I. Gen. Laws §27-29.1-8 (2004)

Reporting/Transparency Requirements

 

Spread Pricing

 

Utilization Management Tools

 

Other

 

South Carolina

Provision

Statute

Cost Disclosure/Gag Clause

S.C. Code Ann. §38-71-2220 (Law. Co-op 2021)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

S.C. Code Ann. §38-71-2240 (Law. Co-op 2021)

Network Adequacy

S.C. Code Ann. §38-71-147 (Law. Co-op 1997)

S.C. Code Ann. §38-71-2230(E) (Law. Co-op 2021)

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

S.C. Code Ann. §38-71-2230 (Law. Co-op 2021)

S.C. Code Ann. §38-71-1830 (Law. Co-op 2013)

Pharmacy Auditing Standards

Appeals Process

S.C. Code Ann. §38-71-1810 (Law. Co-op 2019)

S.C. Code Ann. §38-71-1820 (Law. Co-op 2013)

Registration/Licensure

S.C. Code Ann. §38-71-2210 (Law. Co-op 2021)

Regulatory Agency/Enforcement

S.C. Code Ann. §38-71-2210 (Law. Co-op 2021)

S.C. Code Ann. §38-71-2250 (Law. Co-op 2021)

Reporting/Transparency Requirements

 

Spread Pricing

 

Utilization Management Tools

 

Other

 

South Dakota

Provision

Statute

Cost Disclosure/Gag Clause

S.D. Codified Laws Ann. §58-29E-8.1 (2018)

S.D. Codified Laws Ann. §58-33-135 (2018)

Fiduciary

S.D. Codified Laws Ann. §58-29E-3 (2004)

Maximum Allowable Cost (MAC) Lists

 

Network Adequacy

 

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

S.D. Codified Laws Ann. §58-29E-12 (2019)

S.D. Codified Laws Ann. §58-29E-13 (2019)

S.D. Codified Laws Ann. §58-29F-6 (2013)

Pharmacy Auditing Standards

Appeals Process

S.D. Codified Laws Ann. §58-29F3-F5 (2013)

S.D. Codified Laws Ann. §58-29F-9 (2013)

Registration/Licensure

S.D. Codified Laws Ann. §58-29E-2 (2013)

Regulatory Agency/Enforcement

S.D. Codified Laws Ann. §58-29E-9 (2004)

Reporting/Transparency Requirements

S.D. Codified Laws Ann. §58-29E-4 (2004)

Spread Pricing

 

Utilization Management Tools

 

Other

S.D. Codified Laws Ann. §58-29E-15 (2019) (340B)

Tennessee

Provision

Statute

Cost Disclosure/Gag Clause

Tenn. Code Ann. §56-7-3114 (2018)

Tenn. Code Ann. §56-7-3203 (2010)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

Tenn. Code Ann. §56-7-3106 (2015)

Tenn. Code Ann. §56-7-3107 (2015)

Tenn. Code Ann. §56-7-3108 (2016)

Network Adequacy

 

Patient Steering

Tenn. Code Ann. §56-7-3120 (2021)

Pharmacy Reimbursement

Clawbacks

Tenn. Code Ann. §56-7-3104 (2007)

Tenn. Code Ann. §56-7-3112 (2015)

Tenn. Code Ann. §56-7-3118 (2019)

Pharmacy Auditing Standards

Appeals Process

Tenn. Code Ann. §56-7-3103 (2019)

Registration/Licensure

Tenn. Code Ann. §56-7-3113 (2019)

Regulatory Agency/Enforcement

Tenn. Code Ann. §56-7-3113 (2019)

Reporting/Transparency Requirements

Tenn. Code Ann. §4-3-1021 (2013)

Spread Pricing

 

Utilization Management Tools

 

Other

Tenn. Code Ann. §56-7-3119 (2021) (340B)

Utah

Provision

Statute

Cost Disclosure/Gag Clause

Utah Code Ann. §31A-46-302 4(a) (2020)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

Utah Code Ann. §31A-46-303 (2020)

Network Adequacy

Utah Code Ann. §31A-46-306 (2020)

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

Utah Code Ann. §31A-46-304 (2020)

Utah Code Ann. §31A-46-305 (2020)

Utah Code Ann. §34A-46-309 (2020)

Pharmacy Auditing Standards

Appeals Process

 

Registration/Licensure

Utah Code Ann. §31A-46-201 (2019)

Regulatory Agency/Enforcement

Utah Code Ann. §31A-46-202 (2019)

Utah Code Ann. §31A-2-308 (2019)

Reporting/Transparency Requirements

Utah Code Ann. §31A-46-301 (2020)

Utah Code Ann. §31A-46-307 (2020)

Spread Pricing

 

Utilization Management Tools

 

Other

Utah Code Ann. §34A-46-309 (2020) (340)

Utah Code Ann. §31A-46-310 (2021) (340B)

Vermont

Provision

Statute

Cost Disclosure/Gag Clause

Vt. Stat. Ann. tit. 18,  §9473 (b4, b5) (2021)

Fiduciary

Vt. Stat. Ann. tit. 18, §9472 (2014)

Maximum Allowable Cost (MAC) Lists

Vt. Stat. Ann. tit. 18, §9473 (c) (2021)

Network Adequacy

Vt. Stat. Ann. tit. 8, §4089j (2016)

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

Vt. Stat. Ann. tit. 18, §9473 (2021)

Pharmacy Auditing Standards

Appeals Process

Vt. Stat. Ann. tit. 18, §3802 (2021)

Registration/Licensure

Vt. Stat. Ann. tit. 18, §9421 (a) (2017)

Regulatory Agency/Enforcement

Vt. Stat. Ann. tit. 18, §9421 (a) (2017)

Vt. Stat. Ann. tit. 18, §9421 (e) (2017)

Vt. Stat. Ann. tit. 18, §9474 (2017)

Reporting/Transparency Requirements

Vt. Stat. Ann. tit. 18, §9472 (2014)

Spread Pricing

Vt. Stat. Ann. tit. 18, §9421 (b) (2017)

Vt. Stat. Ann. tit. 18, §9472 (2014)

Utilization Management Tools

 

Other

 

Virginia

Provision

Statute

Cost Disclosure/Gag Clause

 Va. Code §38.2-3407.15:4 (2018)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

Va. Code §38.2-3407.15:3 (2015)

Network Adequacy

Va. Code §38.2-3407.7 (2021)

Va. Code §38.2-3467(C) (2020)

Patient Steering

Va. Code §38.2-4312.1 (2021)

Pharmacy Reimbursement

Clawbacks

Va. Code §38.2-3467(A)(3) (2020)

Pharmacy Auditing Standards

Appeals Process

Va. Code §38.2-3407.15:1 (2019)

Registration/Licensure

Va. Code §38.2-3466 (2020)

Regulatory Agency/Enforcement

Va. Code §38.2-3466 (2020)

Va. Code §38.2-3469 (2020)

Reporting/Transparency Requirements

Va. Code §38.2-3407.15:6 (2022)

Va. Code §38.2-3468 (2020)

Spread Pricing

Va. Code §38.2-3467(D) (2020)

Utilization Management Tools

Va. Code §38.2-3407.9:05 (2020) (Step Therapy)

Va. Code §38.2-3407.15:2 (2021) (Prior Authorization)

Other

 

Washington

Provision

Statute

Cost Disclosure/Gag Clause

 

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

Wash. Rev. Code Ann. §48.200.280 (2022)

Network Adequacy

 

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

Wash. Rev. Code Ann. §48.200.280 (2022)

Pharmacy Auditing Standards

Appeals Process

Wash. Rev. Code Ann. §48.200.220 (2022)

Wash. Rev. Code Ann. §48.200.230 (2022)

Wash. Rev. Code Ann. §48.200.240 (2022)

Wash. Rev. Code Ann. §48.200.250 (2022)

Wash. Rev. Code Ann. §48.200.260 (2022)

Registration/Licensure

Wash. Rev. Code Ann. §19.340.030 (2022)

Wash. Rev. Code Ann. §48.200.030 (2022)

Regulatory Agency/Enforcement

Wash. Rev. Code Ann. §48.200.030 (2022)

Wash. Rev. Code Ann. §48.200.900 (2022)

Wash. Rev. Code Ann. §48.200.290 (2022)

Wash. Rev. Code Ann. §48.200.050 (2022)

Reporting/Transparency Requirements

Wash. Rev. Code Ann. §43.71C.030 (2022)

Spread Pricing

 

Utilization Management Tools

 

Other

 

West Virginia

Provision

Statute

Cost Disclosure/Gag Clause

W. Va. Code §33-51-9(a) (2021)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

 

Network Adequacy

W. Va. Code §33-51-8(d) (2021)

Patient Steering

W. Va. Code §33-51-11 (2021)

Pharmacy Reimbursement

Clawbacks

W. Va. Code §5-16-7G(i) (2020)

This law is specific to cost-sharing requirements for insulin.

W. Va. Code §33-51(9) (2021)

Pharmacy Auditing Standards

Appeals Process

W. Va. Code §33-51-4 (2019)

W. Va. Code §33-51-5 (2017)

W. Va. Code §33-51-6 (2017)

Registration/Licensure

W. Va. Code §33-51-7 (2019)

W. Va. Code §33-51-8 (c) (2021)

Regulatory Agency/Enforcement

W. Va. Code §33-51-8(a) (2021)

W. Va. Code §33-51-8(e) (2021)

W. Va. Code §33-51-10 (2020)

Reporting/Transparency Requirements

W. Va. Code §33-51-12 (2021)

Spread Pricing

 

Utilization Management Tools

 

Other

 W. Va. Code §33-51-9(d) (2021) (340B)

Wisconsin

Provision

Statute

Cost Disclosure/Gag Clause

Wis. Stat. §632.861(2)(a) (2021)  

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

Wis. Stat. §632.865 (2) (2021)

Network Adequacy

Wis. Stat. §632.865 (4) (2021)

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

Wis. Stat. §632.865 (5) (2021)

Pharmacy Auditing Standards

Appeals Process

Wis. Stat. §632.865 (6) (2021)

Registration/Licensure

Wis. Stat. §632.865 (3) (2021)

Regulatory Agency/Enforcement

Wis. Stat. §632.865 (3) (2021)

Reporting/Transparency Requirements

Wis. Stat. §632.865(7) (2021)

Spread Pricing

 

Utilization Management Tools

Wis. Stat. §632.853 (1997) (Formulary Exception)

Wis. Stat. §632.866 (2019) (Step-Therapy)

Other

 

Wyoming

Provision

Statute

Cost Disclosure/Gag Clause

Wyo. Stat. §26-52-104(j) (2019)

Fiduciary

 

Maximum Allowable Cost (MAC) Lists

Wyo. Stat. §26-52-104 (2019)

Network Adequacy

 

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

 

Pharmacy Auditing Standards

Appeals Process

Wyo. Stat. §26-52-103 (2016)

Registration/Licensure

Wyo. Stat. §26-52-101 (2016)

Regulatory Agency/Enforcement

Wyo. Stat. §26-52-101 (2016)

Reporting/Transparency Requirements

 

Spread Pricing

 

Utilization Management Tools

 

Other

 

District of Columbia

Provision

Statute

Cost Disclosure/Gag Clause

D.C. Code Ann. § 48–832.01

Fiduciary

D.C. Code Ann. § 48–832.01

Maximum Allowable Cost (MAC) Lists

 

Network Adequacy

 

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

D.C. Code Ann. § 48–832.01

Pharmacy Auditing Standards

Appeals Process

 

Registration/Licensure

 

Regulatory Agency/Enforcement

D.C. Code Ann. § 48–832.03

Reporting/Transparency Requirements

 

Spread Pricing

D.C. Code Ann. § 48–832.01

Utilization Management Tools

 

Other

 

Puerto Rico

Provision

Statute

Cost Disclosure/Gag Clause

 

Fiduciary

P.R. Laws tit. 26, § 9049 (Insurer Oversight)

Maximum Allowable Cost (MAC) Lists

 

Network Adequacy

 

Patient Steering

 

Pharmacy Reimbursement

Clawbacks

 

Pharmacy Auditing Standards

Appeals Process

 

Registration/Licensure

 

Regulatory Agency/Enforcement

 

Reporting/Transparency Requirements

 

Spread Pricing

 

Utilization Management Tools

P.R. Laws tit. 26, § 9046 (Formularies)

P.R. Laws tit. 26 § 9047 (Step Therapy)

Other

 

Text/HTML

Text/HTML

Glossary

Glossary of terms commonly found in PBM state legislation and statutes which are reflected in the maps.

Cost-Disclosure/Gag-clause

Contracts between a pharmacy and a pharmacy benefit manager (PBM) are a common feature in the prescription drug distribution and sales chain. The terms of these arrangements are often proprietary and unknown to consumers and some purchasers, like employers. The terms can include a “gag clause,” which restricts pharmacists from informing consumers of lower cost options, such as if a consumer purchases a prescription out of pocket rather than using the drug benefit through their insurance plan. Over two-thirds of states have laws that address this issue.

Fiduciary

A fiduciary is a person or entity who holds a legal or ethical responsibility to act in the best interests of their clients. A PBM’s clients typically are health plans whose primary stakeholders are plan enrollees. While some states impose fiduciary responsibilities on PBMs, others require PBMs to exercise good faith and fair dealing while performing their contractual duties. More than a quarter of states have this type of legislation in place.

Maximum Allowable Cost (MAC) Lists

Pharmacy benefit managers may choose to establish an upper limit or maximum amount they will reimburse a pharmacy for generic and multi-source drugs. PBMs develop maximum allowable costs (MAC) lists using a variety of data, resources and information, and these lists may consist of thousands of products. A state may choose to regulate the frequency MAC lists are updated, such as every seven days. Another common approach is providing for an appeals process when a pharmacy disputes an amount they were reimbursed. Only a handful of states have not enacted legislation in this area.

Network Adequacy

A pharmacy network is a list of pharmacies or pharmacists that a health plan or PBM has contracted with to provide prescription drug services to their members. Pharmacy network adequacy is often defined as the distance between a patient’s residence and where services can be physically accessed. Existing state laws generally set adequacy and eligibility standards for network participation.

Patient Steering

Some PBMs require contracted health plan enrollees to visit affiliated pharmacies, or pharmacies in which they have an ownership interest including retail, mail-order or specialty.  Four states – Georgia, Louisiana, Minnesota and Utah – have passed legislation specifically banning this practice.

Pharmacy Auditing Standards/Appeals Process

Audits on pharmacies by PBMs to detect fraud, waste and abuse are routine; however, some states have implemented laws to ensure pharmacies are audited fairly and are given a process for appeal. Over two-thirds of states have enacted some form of a fair pharmacy audit bill which provides guidelines on when and how pharmacy audits are conducted by PBMs.

Pharmacy Reimbursement/Claw Backs

State laws may provide reimbursement standards for pharmacies with which the PBM contracts. For example, a state might prohibit a PBM from denying or reducing the amount they reimburse to a pharmacy or pharmacist for a claim.

Claw backs occur when a health plan enrollee’s copayment exceeds the total cost of the drug to their insurer, and the PBM “claws back” some, or all, of the overpayment from the pharmacy. Some states have chosen to prohibit these types of retroactive payments and at least 22 states have enacted some form of claw back legislation.

Registration/Licensure

States may require PBMs to register or obtain licensure to conduct business, often through the state department of insurance or board of pharmacy. At least thirty states have this type of law.

Regulatory Agency/Enforcement

Many of the same states that require PBM registration or licensure authorize a specific agency to promulgate rules and regulations. Maine has approached the issue uniquely by requiring insurers that contract with PBMs to monitor the PBM’s activities.

Most states that opt to give regulatory oversight of PBM business practices to a specific state agency also give that agency the authority to establish and assess fines, impose civil penalties, and suspend or revoke a license of a PBM that is found to be noncompliant.

Reporting/Transparency Requirements

Some states have implemented laws that require PBMs to disclose certain pricing and cost information such as data on rebates, payments and fees collected from drug manufacturers, insurers, and pharmacies.

Spread Pricing

Health plans choose contracts with PBMs that commonly use either a spread pricing reimbursement model or pass-through pricing model. In a spread pricing model, the PBM keeps a portion of the amount, or spread, between what the health plan pays the PBM and the amount that the PBM reimburses the pharmacy for a beneficiary’s prescription. With a pass-through contract, the PBM passes through the amount charged by the pharmacy to the health insurer. Since no spread is collected, PBMs typically charge an administrative fee. More than a dozen states bar the use of spread pricing models in PBM and health plan contracts.

Utilization Management Tools (e.g., Prior Authorization, Step-Therapy, Non-Medical Switching)

Utilization management tools are used by payers to manage the use and mix of drugs covered under the benefit. A provider might be required to gain prior authorization or approval for a specific treatment before it can be administered. Step therapy, also called “fail first,” is when a patient is required to try certain treatments or prescription drugs before switching to a more expensive or non-generic alternative. Non-medical switching occurs when a patient who is stable on one medicine is switched to another for reasons other than clinical purposes. More than half of states have laws that address utilization management policies. 

Other

Some states have pursued other activities related to PBM reform not highlighted in the above categories. For instance, in a reverse auction PBMs compete for a state’s business and the lowest offer is awarded the contract. Other actions prohibit discriminatory practices against a pharmacy that participates in the federal 340B program.