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ARIZONA HOUSE OF REPRESENTATIVES57th Legislature, 2nd Regular Session |
Senate: RAGE DP 7-0-0-0 | Third Read 29-1-0-0House: HHS DPA/SE 11-1-0-0 |
SB 1458: pharmacy board; civil penalties
S/E: prohibition; providers; patient prescription information
Sponsor: Senator Shamp, LD 29
Caucus & COW
Summary of the Strike-Everything Amendment to SB1458
Overview
Establishes pharmacy benefit manager (PBM) prohibitions on patient steering.
History
A PBM means a person, business or other entity that, pursuant to a contract or under an employment relationship with an insurer or other third-party payor, either directly or through an intermediary manages the prescription drug coverage provided by the insurer or other third-party payor, including the processing and payment of claims for prescription drugs, the performance of drug utilization review, the processing of drug prior authorization requests, the adjudication of appeals or grievances related to prescription drug coverage, contracting with network pharmacies and controlling the cost of covered prescription drugs (A.R.S. § 20-3321)
A PBM must do all of the following: 1) update the price and drug information for each list that the PBM maintains every seven business days; 2) at the beginning of the term of a contract, on renewal of a contract and at least once annually during the term of a contract, make available to each network pharmacy the sources used to determine maximum allowable cost pricing; 3) establish a process by which a network pharmacy may appeal its reimbursement for a drug subject to maximum allowable cost pricing; and 4) allow a pharmacy services administrative organization that is contracted with the PBM to file an appeal of a drug on behalf of the organization's contracted pharmacies (A.R.S. § 20-3331)
Statute prohibits a PBM from: 1) limiting a pharmacist or pharmacy from providing an insured individual information on the amount of the insured’s cost share for the insured’s prescription drug and the clinical efficacy of a more affordable alternative; 2) penalizing a pharmacy or pharmacist for disclosing such information to an insured; and 3) requiring a pharmacist or pharmacy to charge or collect from an insured a copayment that exceeds the total submitted charged by the network pharmacy (A.R.S. § 44-1752).
Provisions
1. Prohibits PBM’s from transferring or receiving from its affiliated provider a record that contains a patient or prescriber identifiable prescription information for a commercial purpose. (Sec. 1)
2. Prohibits PBM’s from directly or indirectly steering a patient to use the PBM’s affiliated provider by doing any of the following:
a. communicating through data mining or other similar processes of patient information that are generated from or obtained through the prescription filing process at a pharmacy, as outlined;
b. attempting to influence a patient to use an affiliated provider; or
c. retaliating against a patient who does not use an affiliated provider. (Sec. 1)
3. Prohibits PBM’s from penalizing a beneficiary or provide an inducement to the beneficiary for the purposes of getting the beneficiary to use a specific retail, mail order or other network pharmacy that is the PBM’s affiliated provider. (Sec. 1)
4. Prohibits PBM’s from soliciting a patient or prescriber to transfer a patient prescription to the PBM’s affiliated provider. (Sec. 1)
5. Prohibits a PBM from requiring a pharmacy or durable medical equipment provider that is not the PBM’s affiliated provider to transfer a patient’s prescription to the affiliated provider without the prior written consent of the patient, unless the patient personally requests the transfer. (Sec. 1)
6. Prohibits PBM’s from paying an affiliated provider a reimbursement amount that is more than the amount the PBM pays a non-affiliated pharmacy or durable medical equipment provider for the same product or service. (Sec. 1)
7. Prohibits PBM’s from committing unfair and deceptive trade practices as prescribed in statute. (Sec. 1)
8. Applies the patient steering prohibitions to any PBM acting on its own behalf or on behalf of an insurer. (Sec. 1)
9. Exempts health and accident insurance coverage that is obtained by the Arizona Department of Administration from the patient steering prohibitions. (Sec. 1)
10. Allows the Department of Insurance and Financial Institutions to investigate any violations relating to patient steering. (Sec. 1)
11. Deems any conduct in violation of the patient steering prohibitions that is performed with such frequency as to indicate a general business practice constitutes an unlawful practice and subject to the consumer fraud regulations. (Sec. 1)
12. Clarifies that commercial purposes do not include:
a. pharmacy reimbursement;
b. formulary compliance;
c. pharmaceutical care; or
d. utilization review by a health care provider or a public health activity authorized by law. (Sec. 1)
13. Clarifies the patient steering prohibitions do not prevent a PBM from including its affiliated provider in a patient or prospective patient communication if the communication:
a. regard information about the cost or service provided by pharmacies or durable medical equipment providers in the network of a health benefits plan in which the patient or prospective patient is enrolled; and
b. includes accurate comparable information regarding pharmacies or durable medical equipment providers in the network that are not the issuer’s or PBM’s affiliated providers. (Sec. 1)
14. Defines terms. (Sec. 1)
15. Applies the patient steering prohibitions to contracts entered into, amended, extended or renewed by the general effective date. (Sec. 1)
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19. Initials AG SB 1458
20. 3/20/2026 Page 0 Caucus & COW
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