S.F. 333 Section 1. Section 510B.8, Code 2023, is amended by adding 1 the following new subsections: 2 NEW SUBSECTION . 3. Any amount paid by a covered person for 3 a prescription drug purchased pursuant to this section shall 4 be applied to any deductible imposed by the covered person’s 5 health benefit plan in accordance with the health benefit plan 6 coverage documents. 7 NEW SUBSECTION . 4. A covered person shall not be prohibited 8 from filling a prescription drug order at any pharmacy located 9 in the state provided that the pharmacy accepts the same terms 10 and conditions as the pharmacies participating in the covered 11 person’s health benefit plan’s network. 12 NEW SUBSECTION . 5. Excluding incentives in value-based 13 programs established by a health carrier or a pharmacy benefits 14 manager to promote the use of higher quality pharmacies, 15 a pharmacy benefits manager shall not impose different 16 cost-sharing or additional fees on a covered person based on 17 the pharmacy at which the covered person fills the covered 18 person’s prescription drug order. 19 NEW SUBSECTION . 6. A pharmacy benefits manager shall 20 not require a covered person, as a condition of payment 21 or reimbursement, to purchase pharmacy services, including 22 prescription drugs, exclusively through a mail-order pharmacy. 23 Sec. 2. Section 510B.8A, subsection 2, paragraph a, Code 24 2023, is amended to read as follows: 25 a. Provide each pharmacy in a pharmacy network reasonable 26 access to the maximum allowable cost list to which the pharmacy 27 is subject via a secure accessible internet site . 28 Sec. 3. NEW SECTION . 510B.8D Appeals and disputes. 29 1. A pharmacy benefits manager shall provide a reasonable 30 process to allow a pharmacy to appeal a maximum allowable cost 31 or reimbursement rate for a specific prescription drug for any 32 of the following reasons: 33 a. The pharmacy benefits manager violated section 510B.8A. 34 b. The maximum allowable cost or the reimbursement rate is 35 -1- LSB 1508XS (2) 90 ko/rn 1/ 4

S.F. 333 below the pharmacy acquisition cost. 1 2. The appeal process must include all of the following: 2 a. A dedicated telephone number at which a pharmacy may 3 contact the pharmacy benefits manager and speak directly with 4 an individual involved in the appeal process. 5 b. A dedicated electronic mail address or internet site for 6 the purpose of submitting an appeal directly to the pharmacy 7 benefits manager. 8 c. A period of at least thirty business days after the date 9 of a pharmacy’s initial submission of a clean claim during 10 which the pharmacy may initiate an appeal. 11 3. A pharmacy benefits manager shall respond to an appeal 12 within seven business days after the date on which the pharmacy 13 benefits manager receives the appeal. 14 a. If the pharmacy benefits manager grants a pharmacy’s 15 appeal, the pharmacy benefits manager shall do all of the 16 following: 17 (1) Adjust the maximum allowable cost or the reimbursement 18 rate of the prescription drug that is the subject of the appeal 19 and provide the national drug code number that the adjustment 20 is based on to the appealing pharmacy. 21 (2) Permit the appealing pharmacy to reverse and resubmit 22 the claim that is the subject of the appeal. 23 (3) Make the adjustment pursuant to subparagraph (1) 24 applicable to all of the following: 25 (a) Each pharmacy that is under common ownership with the 26 pharmacy that submitted the appeal. 27 (b) Each pharmacy in the state that demonstrates the 28 inability to purchase the prescription drug for less than the 29 established maximum allowable cost or reimbursement rate. 30 b. If the pharmacy benefits manager denies a pharmacy’s 31 appeal, the pharmacy benefits manager shall do all of the 32 following: 33 (1) Provide the appealing pharmacy the national drug 34 code number and the name of a wholesale distributor licensed 35 -2- LSB 1508XS (2) 90 ko/rn 2/ 4

S.F. 333 pursuant to section 155A.17 from which the pharmacy can obtain 1 the prescription drug at or below the maximum allowable cost 2 or reimbursement rate. 3 (2) If the prescription drug identified by the national drug 4 code number provided by the pharmacy benefits manager pursuant 5 to subparagraph (1) is not available below the pharmacy 6 acquisition cost from the wholesale distributor from whom the 7 pharmacy purchases the majority of its prescription drugs for 8 resale, the pharmacy benefits manager shall adjust the maximum 9 allowable cost or the reimbursement rate above the appealing 10 pharmacy’s pharmacy acquisition cost, and permit the pharmacy 11 to reverse and resubmit each claim affected by the pharmacy’s 12 inability to procure the prescription drug at a cost that is 13 equal to or less than the previously appealed maximum allowable 14 cost or the reimbursement rate. 15 Sec. 4. APPLICABILITY. This Act applies to pharmacy 16 benefits managers that manage a health carrier’s prescription 17 drug benefit in the state on or after the effective date of 18 this Act. 19 EXPLANATION 20 The inclusion of this explanation does not constitute agreement with 21 the explanation’s substance by the members of the general assembly. 22 This bill relates to pharmacy benefits managers (PBM), 23 pharmacies, and prescription drug benefits. 24 The bill requires that any amount paid by a covered person 25 for a drug in the circumstances detailed in the bill must 26 be applied to any deductible imposed by the covered person’s 27 health benefit plan in accordance with the plan’s coverage 28 documents. Under the bill, a covered person cannot be 29 prohibited from filling a drug order at any pharmacy located in 30 the state if the pharmacy accepts the same terms and conditions 31 as the covered person’s benefit plan. A PBM cannot impose 32 different cost-sharing or additional fees on a covered person 33 based on the pharmacy at which a covered person fills their 34 prescription. A PBM cannot require a covered person, as a 35 -3- LSB 1508XS (2) 90 ko/rn 3/ 4

S.F. 333 condition of payment or reimbursement, to purchase pharmacy 1 services, including drugs, exclusively through a mail-order 2 pharmacy. 3 The bill requires a PBM to provide each pharmacy in a network 4 access to the maximum allowable cost list (MACL) to which the 5 pharmacy is subject via a secure accessible internet site. 6 The bill requires a PBM to provide a process for pharmacies 7 to appeal a maximum allowable cost, or a reimbursement made 8 under a MACL. The requirements for the appeal process are 9 detailed in the bill. 10 The bill applies to PBMs that manage a health carrier’s 11 prescription drug benefit in the state on or after the 12 effective date of the bill. 13 -4- LSB 1508XS (2) 90 ko/rn 4/ 4