HB 1236: INSURANCE: Provides relative to pharmacy benefit managers reimbursements (EN +$2,265,844 SG EX See Note) - Louisiana

HB1236 Original → HB1236 Act 913 · 8 edits

MODERATE

This bill updates Louisiana's pharmacy reimbursement laws to increase transparency and protect pharmacy profits from arbitrary adjustments by pharmacy benefit managers (PBMs). It mandates that PBMs use specific pricing benchmarks like NADAC or wholesale acquisition costs, requires a minimum professional dispensing fee based on actual pharmacy labor, and strictly prohibits PBMs from defining costs at their own discretion.

Scope change

The bill applies to all pharmacy benefit managers administering claims for health plans in Louisiana, with a specific exemption for the Office of Group Benefits.

REQUIREMENT

PBMs must adopt a reimbursement formula using NADAC or wholesale acquisition cost as the pricing benchmark, or an alternative approved by the commissioner that results in payment errors smaller than NADAC.

PBMs must use an adjustment factor based on claims experience data that is expected to result in a claim payment error rate of no more than two percent per drug.

PBMs must include a professional dispensing fee in their reimbursement formula that is at least equal to the fee established by the Louisiana Department of Health for Medicaid.

PBMs are prohibited from collecting, recouping, or recovering the professional dispensing fee from pharmacies, pharmacists, or members.

An appeal process must be established for pharmacists to challenge claim payment errors, requiring PBMs to include a written invoice from the wholesaler in the appeal.

DEFINITION

New definitions for 'Acquisition cost' and 'Professional dispensing fee' were added to clarify that acquisition costs are based on actual invoices and that professional fees must cover specific labor costs like counseling and filling.

The previous definition allowing PBMs to define acquisition costs at their sole discretion was removed.

TIMELINE

The effective date for these new PBM requirements was set to January 1, 2026.

HB1236 Enrolled → HB1236 Original · 5 edits

MODERATE

The bill was renumbered from an enrolled substitute to an original version and its title was simplified to focus on pharmacy benefit manager reimbursements. The substantive legal text remains largely consistent, though minor formatting adjustments and a slight reordering of the effective date clause were made.

Scope change

The scope of the bill remains unchanged; it continues to regulate pharmacy benefit managers and local pharmacies in Louisiana regarding reimbursement formulas and definitions.

TECHNICAL

The bill header was updated from 'ENROLLED' to 'ORIGINAL' and the bill number was corrected to reflect the original filing.

The bill title was shortened from a detailed list of provisions to a concise summary: 'INSURANCE: Provides relative to pharmacy benefit managers reimbursements'.

The effective date clause was restructured to appear earlier in the section, clarifying that the new rules apply to claims submitted on or after January 1, 2026.

DEFINITION

Minor text adjustments were made to the definition of 'Acquisition cost' to improve clarity and consistency with standard pricing terms.

REQUIREMENT

The text regarding the 'professional dispensing fee' was slightly rephrased to ensure it clearly reflects actual pharmacist costs and physical dispensing expenses.

HB1236 Reengrossed → HB1236 Enrolled · 2 edits · Jun 1, 2026

MINOR

The bill was transitioned from a reengrossed version to an enrolled version, finalizing its text for signature. The substantive policy content remains consistent, focusing on regulating pharmacy benefit manager reimbursements to ensure they cover actual drug acquisition costs and professional dispensing fees. The enrolled version includes minor formatting adjustments, such as adding a second representative to the sponsor list and updating page counts, while retaining the core requirements for reimbursement formulas and appeal processes.

Scope change

The scope of the bill remains unchanged; it continues to apply to pharmacy benefit managers administering claims for local pharmacies in Louisiana.

TECHNICAL

The bill text was finalized for signature, changing the status from 'Reengrossed' to 'Enrolled' and updating the sponsor list to include Representatives Dewitt and Echols.

Minor formatting adjustments were made throughout the document, including updating page numbers and reorganizing the layout of definitions and requirements.

HB1236 Engrossed → HB1236 Reengrossed · 5 edits · May 19, 2026

MODERATE

The bill was reengrossed to add a new section (1868.2) and modify existing definitions regarding pharmacy reimbursement. Key changes include updating the definition of 'acquisition cost' to ensure it is not determined solely by pharmacy benefit managers, adding a new definition for 'reimbursement formula,' and replacing a specific requirement for a professional dispensing fee with a mandate to adopt an appeal process for pharmacists to challenge low reimbursements.

Scope change

The bill's scope expanded to include new provisions for pharmacy reimbursement formulas and a formalized appeal process for pharmacists, while also adding a new section to the statute.

REQUIREMENT

Added a new section (1868.2) requiring the adoption of an appeal process for pharmacists to challenge claim payment errors.

Replaced a requirement to adopt a specific professional dispensing fee with a requirement to adopt an appeal process for pharmacists.

Updated the reimbursement formula requirement to specify that it must include an ingredient price, an adjustment factor, and a professional dispensing fee.

DEFINITION

Modified the definition of 'acquisition cost' to explicitly state it cannot be defined or determined at the sole discretion of a pharmacy benefit manager.

Added a new definition for 'reimbursement formula' to clarify how drug reimbursement calculations should be structured.

INSURANCE: Provides relative to pharmacy benefit managers reimbursements (EN +$2,265,844 SG EX See Note)

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