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1 STATE OF OKLAHOMA
2 1st Session of the 60th Legislature (2025)
3 HOUSE BILL 2817 By: Marti
4
5
6 AS INTRODUCED
7 An Act relating to health care; creating the Oklahoma
Rebate Pass-Through and Pharmacy Benefits Manager
8 Meaningful Transparency Act of 2025; providing cost
sharing calculation methodology, limitations, and
9 requirements; creating penalties; clarifying
authority to take certain actions; prohibiting the
10 disclosure of certain information; declaring that
certain information not be considered public record;
11 amending 36 O.S. 2021, Section 6960, as last amended
by Section 1, Chapter 306, O.S.L. 2024 (36 O.S. Supp.
12 2024, Section 6960), which relates to definitions;
defining terms; creating PBM disclosures; amending 36
13 O.S. 2021, Section 6962, as last amended by Section
2, Chapter 306, O.S.L. 2024 (36 O.S. Supp. 2024,
14 Section 6962), which relates to pharmacy benefits
manager compliance; creating duties; amending 36 O.S.
15 2021, Section 6964, which relates to a formulary for
prescription drugs; creating agency duties; amending
16 59 O.S. 2021, Section 357, as amended by Section 4,
Chapter 332, O.S.L. 2024 (59 O.S. Supp. 2024, Section
17 357), which relates to definitions; modifying
definitions; amending 59 O.S. 2021, Section 358, as
18 amended by Section 5, Chapter 332, O.S.L. 2024 (59
O.S. Supp. 2024, Section 358), which relates to
19 pharmacy benefits management licensure, procedure,
and penalties; creating duties; creating licensing
20 application requirements; providing for
noncodification; providing for codification; and
21 providing an effective date.
22
23
24 BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
Req. No. 11292 Page 1
1 SECTION 1. NEW LAW A new section of law not to be
2 codified in the Oklahoma Statutes reads as follows:
3 This act shall be known and may be cited as the "Oklahoma Rebate
4 Pass-Through and Pharmacy Benefits Manager Meaningful Transparency
5 Act of 2025".
6 SECTION 2. NEW LAW A new section of law to be codified
7 in the Oklahoma Statutes as Section 6962.2 of Title 36, unless there
8 is created a duplication in numbering, reads as follows:
9 A. An enrollee's defined cost sharing for each prescription
10 drug shall be calculated at the point of sale based on a price that
11 is reduced by an amount equal to at least eighty-five percent (85%)
12 of all rebates received, or to be received, in connection with the
13 dispensing or administration of the prescription drug.
14 B. For any violation of this section, the Insurance
15 Commissioner may subject a pharmacy benefits manager (PBM) to an
16 administrative penalty of not less than One Hundred Dollars
17 ($100.00) nor more than Ten Thousand Dollars ($10,000.00) for each
18 occurrence. Such administrative penalty may be enforced in the same
19 manner in which civil judgments may be enforced.
20 C. Nothing in subsections A and B of this section shall
21 preclude a PBM from decreasing an enrollee's defined cost sharing by
22 an amount greater than that required under subsection A of this
23 section.
24
Req. No. 11292 Page 2
1 D. In implementing the requirements of this section, the state
2 shall only regulate a PBM to the extent permissible under applicable
3 law.
4 E. In complying with the provisions of this section, a PBM or
5 its agents shall not publish or otherwise reveal information
6 regarding the actual amount of rebates a PBM receives on a product
7 or therapeutic class of products, manufacturer, or pharmacy-specific
8 basis. Such information is protected as a trade secret, is not a
9 public record as defined in the Oklahoma Open Records Act, Section
10 24A.1 et seq. of Title 51 of the Oklahoma Statutes, and shall not be
11 disclosed directly or indirectly, or in a manner that would allow
12 for the identification of an individual product, therapeutic class
13 of products, or manufacturer, or in a manner that would have the
14 potential to compromise the financial, competitive, or proprietary
15 nature of the information. A PBM shall impose the confidentiality
16 protections of this section on any vendor or downstream third party
17 that performs health care or administrative services on behalf of
18 the insurer that may receive or have access to rebate information.
19 SECTION 3. NEW LAW A new section of law to be codified
20 in the Oklahoma Statutes as Section 6970 of Title 36, unless there
21 is created a duplication in numbering, reads as follows:
22 A. For purposes of this section:
23
24
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1 1. "Defined cost sharing" means a deductible payment or
2 coinsurance amount imposed on an enrollee for a covered prescription
3 drug under the enrollee's health plan;
4 2. "Insurer" means any health insurance issuer that is subject
5 to state law regulating insurance and offers health insurance
6 coverage, as defined in 42 U.S.C., Section 300gg-91, or any state or
7 local governmental employer plan;
8 3. "Price protection rebate" means a negotiated price
9 concession that accrues directly or indirectly to the insurer, or
10 other party on behalf of the insurer, in the event of an increase in
11 the wholesale acquisition cost of a drug above a specified
12 threshold;
13 4. "Rebate" means:
14 a. negotiated price concessions including, but not
15 limited to, base price concessions (whether described
16 as a rebate or otherwise) and reasonable estimates of
17 any price protection rebates and performance-based
18 price concessions that may accrue directly or
19 indirectly to the insurer during the coverage year
20 from a manufacturer, dispensing pharmacy, or other
21 party in connection with the dispensing or
22 administration of a prescription drug, and
23 b. reasonable estimates of any negotiated price
24 concessions, fees, and other administrative costs that
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1 are passed through, or are reasonably anticipated to
2 be passed through, to the insurer and serve to reduce
3 the insurer's liabilities for a prescription drug.
4 B. An enrollee's defined cost sharing for each prescription
5 drug shall be calculated at the point of sale based on a price that
6 is reduced by an amount equal to at least eighty-five percent (85%)
7 of all rebates received, or to be received, in connection with the
8 dispensing or administration of the prescription drug.
9 C. For any violation of this section, the Insurance
10 Commissioner may subject an insurer to an administrative penalty of
11 not less than One Hundred Dollars ($100.00) nor more than Ten
12 Thousand Dollars ($10,000.00) for each occurrence. Such
13 administrative penalty may be enforced in the same manner in which
14 civil judgments may be enforced.
15 D. Nothing in subsections A through C of this section shall
16 preclude an insurer from decreasing an enrollee's defined cost
17 sharing by an amount greater than that required under subsection B
18 of this section.
19 E. In implementing the requirements of this section, the state
20 shall only regulate an insurer to the extent permissible under
21 applicable law.
22 F. In complying with the provisions of this section, an insurer
23 or its agents shall not publish or otherwise reveal information
24 regarding the actual amount of rebates an insurer receives on a
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1 product or therapeutic class of products, manufacturer, or pharmacy-
2 specific basis. Such information is protected as a trade secret, is
3 not a public record as defined in the Oklahoma Open Records Act,
4 Section 24A.1 et seq. of Title 51 of the Oklahoma Statutes, and
5 shall not be disclosed directly or indirectly, or in a manner that
6 would allow for the identification of an individual product,
7 therapeutic class of products, or manufacturer, or in a manner that
8 would have the potential to compromise the financial, competitive,
9 or proprietary nature of the information. An insurer shall impose
10 the confidentiality protections of this section on any vendor or
11 downstream third party that performs health care or administrative
12 services on behalf of the insurer and that may receive or have
13 access to rebate information.
14 SECTION 4. AMENDATORY 36 O.S. 2021, Section 6960, as
15 last amended by Section 1, Chapter 306, O.S.L. 2024 (36 O.S. Supp.
16 2024, Section 6960), is amended to read as follows:
17 Section 6960. A. For purposes of the Patient's Right to
18 Pharmacy Choice Act:
19 1. "Administrative fees" means fees or payments from
20 pharmaceutical manufacturers to, or otherwise retained by, a
21 pharmacy benefits manager (PBM) or its designee pursuant to a
22 contract between a PBM or affiliate and the manufacturer in
23 connection with the PBM's administering, invoicing, allocating, and
24 collecting the rebates;
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1 2. "Aggregate retained rebate percentage" means the percentage
2 of all rebates received by a PBM from all pharmaceutical
3 manufacturers which is not passed on to the PBM's health plan or
4 health insurer clients. Aggregate retained rebate percentage shall
5 be expressed without disclosing any identifying information
6 regarding any health plan, prescription drug, or therapeutic class,
7 and shall be calculated by dividing:
8 a. the aggregate dollar amount of all rebates that the
9 PBM received during the prior calendar year from all
10 pharmaceutical manufacturers and did not pass through
11 to the PBM's health plan or health insurer clients, by
12 b. the aggregate dollar amount of all rebates that the
13 pharmacy benefits manager received during the prior
14 calendar year from all pharmaceutical manufacturers;
15 3. "Covered entity" means a nonprofit hospital or medical
16 service organization, for-profit hospital or medical service
17 organization, insurer, health benefit plan, health maintenance
18 organization, health program administered by the state in the
19 capacity of providing health coverage, or an employer, labor union,
20 or other group of persons that provides health coverage to persons
21 in this state. This term does not include a health plan that
22 provides coverage only for accidental injury, specified disease,
23 hospital indemnity, disability income, or other limited benefit
24
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1 health insurance policies and contracts that do not include
2 prescription drug coverage;
3 4. "Defined cost sharing" means a deductible payment or
4 coinsurance amount imposed on an enrollee for a covered prescription
5 drug under the enrollee's health plan;
6 5. "Formulary" means a list of prescription drugs, as well as
7 accompanying tiering and other coverage information, that has been
8 developed by an issuer, a health plan, or the designee of a health
9 insurer or health plan, which the health insurer, health plan, or
10 designee of the health insurer or health plan references in
11 determining applicable coverage and benefit levels;
12 6. "Generic equivalent" means a drug that is designated to be
13 therapeutically equivalent, as indicated by the United States Food
14 and Drug Administration's "Approved Drug Products with Therapeutic
15 Equivalence Evaluations"; provided, however, that a drug shall not
16 be considered a generic equivalent until the drug becomes nationally
17 available;
18 2. 7. "Health insurer" means any corporation, association,
19 benefit society, exchange, partnership or individual subject to
20 state law required insurance and licensed by under the Oklahoma
21 Insurance Code;
22 8. "Health insurer administrative service fees" means fees or
23 payments from a health insurer or a designee of the health insurer
24 to, or otherwise retained by, a PBM or its designee pursuant to a
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1 contract between a PBM or affiliate, and the health insurer or
2 designee of the health insurer in connection with the PBM managing
3 or administering the pharmacy benefit and administering, invoicing,
4 allocating, and collecting rebates;
5 3. 9. "Health insurer payor" means a health insurance company,
6 health maintenance organization, union, hospital and medical
7 services organization or any entity providing or administering a
8 self-funded health benefit plan;
9 10. "Health plan" means a policy, contract, certification, or
10 agreement offered or issued by a health insurer to provide, deliver,
11 arrange for, pay for, or reimburse any of the costs of health
12 services;
13 4. 11. "Mail-order pharmacy" means a pharmacy licensed by this
14 state that primarily dispenses and delivers covered drugs via common
15 carrier;
16 12. "Pharmacy and therapeutics committee" or "P&T committee"
17 means a committee at a hospital or a health insurance plan that
18 decides which drugs will appear on that entity's drug formulary;
19 5. 13. "Pharmacy benefits manager" or "PBM" means a person,
20 business, or other entity that, either directly or through an
21 intermediary, performs pharmacy benefits management, as defined in
22 paragraph 6 of Section 357 of Title 59 of the Oklahoma Statutes.
23 The term shall include a person or entity acting on behalf of a PBM
24 in a contractual or employment relationship in the performance of
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1 pharmacy benefits management for a managed care company, nonprofit
2 hospital, medical service organization, insurance company, third-
3 party payor or a health program administered by a department of this
4 state. PBM does not include a Pharmacy Services Administrative
5 Organization;
6 6. 14. "Pharmacy benefits management" means a service provided
7 to covered entities to facilitate the provisions of prescription
8 drug benefits to covered individuals within the state, including,
9 but not limited to, negotiating pricing and other terms with drug
10 manufacturers and providers. Pharmacy benefits management may
11 include any or all of the following services:
12 a. claims processing, retail network management, and
13 payment of claims to pharmacies for prescription drugs
14 dispensed to covered individuals,
15 b. administration or management of pharmacy discount
16 cards or programs,
17 c. clinical formulary development and management
18 services, or
19 d. rebate contracting and administration;
20 15. "Price protection rebate" means a negotiated price
21 concession that accrues directly or indirectly to the health
22 insurer, or other party on behalf of the health insurer, in the
23 event of an increase in the wholesale acquisition of a drug above a
24 specified threshold;
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1 7. 16. "Provider" means a pharmacy, as defined in Section 353.1
2 of Title 59 of the Oklahoma Statutes or an agent or representative
3 of a pharmacy;
4 17. "Rebates" means:
5 a. negotiated price concessions including, but not
6 limited to, base price concessions (whether described
7 as a rebate or otherwise) and reasonable estimates of
8 any price protection rebates and performance-based
9 price concessions that may accrue directly or
10 indirectly to a health insurer, health plan, or PBM
11 during the coverage year from a manufacturer,
12 dispensing pharmacy, or other party in connection with
13 the dispensing or administration of a prescription
14 drug, and
15 b. reasonable estimates of any price concessions, fees,
16 and other administrative costs that are passed
17 through, or are reasonably anticipated to be passed
18 through, to a health insurer, health plan, or PBM and
19 serve to reduce the health insurer, health plan, or
20 PBM's liabilities for a prescription drug;
21 8. 18. "Retail pharmacy network" means retail pharmacy
22 providers contracted with a PBM in which the pharmacy primarily
23 fills and sells prescriptions via a retail, storefront location;
24
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1 9. 19. "Rural service area" means a five-digit ZIP code in
2 which the population density is less than one thousand (1,000)
3 individuals per square mile;
4 10. 20. "Spread pricing" means a prescription drug pricing
5 model utilized by a pharmacy benefits manager in which the PBM
6 charges a health benefit plan a contracted price for prescription
7 drugs that differs from the amount the PBM directly or indirectly
8 pays the pharmacy or pharmacist for providing pharmacy services;
9 11. 21. "Suburban service area" means a five-digit ZIP code in
10 which the population density is between one thousand (1,000) and
11 three thousand (3,000) individuals per square mile; and
12 12. 22. "Urban service area" means a five-digit ZIP code in
13 which the population density is greater than three thousand (3,000)
14 individuals per square mile.
15 B. Nothing in the definitions of pharmacy benefits manager or
16 pharmacy benefits management as such terms are defined in the
17 Patient's Right to Pharmacy Choice Act, the Pharmacy Audit Integrity
18 Act, or Sections 357 through 360 of Title 59 of the Oklahoma
19 Statutes shall be construed to deem the following entities to be a
20 pharmacy benefits manager:
21 1. An employer of its own self-funded health benefit plan,
22 except, to the extent permitted by applicable law, where the
23 employer without the utilization of a third party and unrelated to
24 the employer's own pharmacy:
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1 a. negotiates directly with drug manufacturers,
2 b. processes claims on behalf of its members, or
3 c. manages its own retail network of pharmacies; or
4 2. A pharmacy that provides a patient with a discount card or
5 program that is for exclusive use at the pharmacy offering the
6 discount.
7 SECTION 5. AMENDATORY 36 O.S. 2021, Section 6962, as
8 last amended by Section 2, Chapter 306, O.S.L. 2024 (36 O.S. Supp.
9 2024, Section 6962), is amended to read as follows:
10 Section 6962. A. The Attorney General shall review and approve
11 retail pharmacy network access for all pharmacy benefits managers
12 (PBMs) to ensure compliance with Section 6961 of this title.
13 B. A PBM, or an agent of a PBM, shall not:
14 1. Cause or knowingly permit the use of advertisement,
15 promotion, solicitation, representation, proposal or offer that is
16 untrue, deceptive or misleading;
17 2. Charge a pharmacist or pharmacy a fee related to the
18 adjudication of a claim including without limitation a fee for:
19 a. the submission of a claim,
20 b. enrollment or participation in a retail pharmacy
21 network, or
22 c. the development or management of claims processing
23 services or claims payment services related to
24 participation in a retail pharmacy network;
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1 3. Reimburse a pharmacy or pharmacist in the state an amount
2 less than the amount that the PBM reimburses a pharmacy owned by or
3 under common ownership with a PBM for providing the same covered
4 services. The reimbursement amount paid to the pharmacy shall be
5 equal to the reimbursement amount calculated on a per-unit basis
6 using the same generic product identifier or generic code number
7 paid to the PBM-owned or PBM-affiliated pharmacy;
8 4. Deny a provider the opportunity to participate in any
9 pharmacy network at preferred participation status if the provider
10 is willing to accept the terms and conditions that the PBM has
11 established for other providers as a condition of preferred network
12 participation status;
13 5. Deny, limit or terminate a provider's contract based on
14 employment status of any employee who has an active license to
15 dispense, despite probation status, with the State Board of
16 Pharmacy;
17 6. Retroactively deny or reduce reimbursement for a covered
18 service claim after returning a paid claim response as part of the
19 adjudication of the claim, unless:
20 a. the original claim was submitted fraudulently, or
21 b. to correct errors identified in an audit, so long as
22 the audit was conducted in compliance with Sections
23 356.2 and 356.3 of Title 59 of the Oklahoma Statutes;
24
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1 7. Fail to make any payment due to a pharmacy or pharmacist for
2 covered services properly rendered in the event a PBM terminates a
3 provider from a pharmacy benefits manager network;
4 8. Conduct or practice Either directly or through an
5 intermediary, agent, or affiliate, engage in, facilitate, or enter
6 into a contract with another person involving spread pricing, as
7 defined in Section 6960 of this title, in this state; or
8 9. Charge a pharmacist or pharmacy a fee related to
9 participation in a retail pharmacy network including but not limited
10 to the following:
11 a. an application fee,
12 b. an enrollment or participation fee,
13 c. a credentialing or re-credentialing fee,
14 d. a change of ownership fee, or
15 e. a fee for the development or management of claims
16 processing services or claims payment services; or
17 10. Prohibit or penalize a pharmacy or pharmacist for:
18 a. disclosing to an individual information regarding the
19 existence and clinical efficacy of a generic
20 equivalent that would be less expensive to the
21 enrollee:
22 (1) under his or her health plan prescription drug
23 benefit, or
24
Req. No. 11292 Page 15
1 (2) outside his or her health plan prescription drug
2 benefit, without requesting any health plan
3 reimbursement, than the drug that was originally
4 prescribed, or
5 b. selling to an individual, instead of a particular
6 prescribed drug, a therapeutically equivalent drug
7 that would be less expensive to the enrollee:
8 (1) under his or her health plan prescription drug
9 benefit, or
10 (2) outside his or her health plan prescription drug
11 benefit, without requesting any health plan
12 reimbursement, than the drug that was originally
13 prescribed.
14 C. The prohibitions under this section shall apply to contracts
15 between pharmacy benefits managers and providers for participation
16 in retail pharmacy networks.
17 1. A PBM contract shall:
18 a. not restrict, directly or indirectly, any pharmacy
19 that dispenses a prescription drug from informing, or
20 penalize such pharmacy for informing, an individual of
21 any differential between the individual's out-of-
22 pocket cost or coverage with respect to acquisition of
23 the drug and the amount an individual would pay to
24 purchase the drug directly, and
Req. No. 11292 Page 16
1 b. ensure that any entity that provides pharmacy benefits
2 management services under a contract with any such
3 health plan or health insurance coverage does not,
4 with respect to such plan or coverage, restrict,
5 directly or indirectly, a pharmacy that dispenses a
6 prescription drug from informing, or penalize such
7 pharmacy for informing, a covered individual of any
8 differential between the individual's out-of-pocket
9 cost under the plan or coverage with respect to
10 acquisition of the drug and the amount an individual
11 would pay for acquisition of the drug without using
12 any health plan or health insurance coverage.
13 2. A pharmacy benefits manager's contract with a provider shall
14 not prohibit, restrict, or limit disclosure of information or
15 documents to the Attorney General, law enforcement or state and
16 federal governmental officials investigating or examining a
17 complaint or conducting a review of a pharmacy benefits manager's
18 compliance with the requirements under the Patient's Right to
19 Pharmacy Choice Act, the Pharmacy Audit Integrity Act, and Sections
20 357 through 360 of Title 59 of the Oklahoma Statutes.
21 D. A pharmacy benefits manager shall:
22 1. Establish and maintain an electronic claim inquiry
23 processing system using the National Council for Prescription Drug
24
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1 Programs' current standards to communicate information to pharmacies
2 submitting claim inquiries;
3 2. Fully disclose to insurers, self-funded employers, unions or
4 other PBM clients the existence of the respective aggregate
5 prescription drug discounts, rebates received from drug
6 manufacturers and pharmacy audit recoupments;
7 3. Provide the Attorney General, insurers, self-funded employer
8 plans and unions unrestricted audit rights of and access to the
9 respective PBM pharmaceutical manufacturer and provider contracts,
10 plan utilization data, plan pricing data, pharmacy utilization data
11 and pharmacy pricing data;
12 4. Maintain, for no less than three (3) years, documentation of
13 all network development activities including but not limited to
14 contract negotiations and any denials to providers to join networks.
15 This documentation shall be made available to the Attorney General
16 upon request; and
17 5. Report to the Attorney General, on a quarterly basis for
18 each health insurer payor, on the following information:
19 a. the aggregate amount of rebates received by the PBM,
20 b. the aggregate amount of rebates distributed to the
21 appropriate health insurer payor,
22 c. the aggregate amount of rebates passed on to the
23 enrollees of each health insurer payor at the point of
24 sale that reduced the applicable deductible,
Req. No. 11292 Page 18
1 copayment, coinsure or other cost sharing amount of
2 the enrollee,
3 d. the individual and aggregate amount paid by the health
4 insurer payor to the PBM for pharmacy services
5 itemized by pharmacy, drug product and service
6 provided, and
7 e. the individual and aggregate amount a PBM paid a
8 provider for pharmacy services itemized by pharmacy,
9 drug product and service provided.
10 E. Nothing in the Patient's Right to Pharmacy Choice Act shall
11 prohibit the Attorney General from requesting and obtaining detailed
12 data, including raw data, in response to the information provided by
13 a PBM in the quarterly reports required by this section. The
14 Attorney General may alter the frequency of the reports required by
15 this section at his or her sole discretion.
16 F. The Attorney General may promulgate rules to implement the
17 provisions of the Patient's Right to Pharmacy Choice Act, the
18 Pharmacy Audit Integrity Act, and Sections 357 through 360 of Title
19 59 of the Oklahoma Statutes.
20 SECTION 6. AMENDATORY 36 O.S. 2021, Section 6964, is
21 amended to read as follows:
22 Section 6964. A. A health insurer's insurer or its agent's,
23 including pharmacy benefits managers, pharmacy and therapeutics
24 committee (P&T committee) shall establish a formulary, which shall
Req. No. 11292 Page 19
1 be a list of prescription drugs, both generic and brand name, used
2 by practitioners to identify drugs that offer the greatest overall
3 value.
4 B. A health insurer shall prohibit conflicts of interest for
5 members of the P&T committee. The P&T committee shall review the
6 formulary annually and must meet the following requirements:
7 1. A person may not serve on a P&T committee if the person is
8 currently employed or was employed within the preceding year by a
9 pharmaceutical manufacturer, developer, labeler, wholesaler or
10 distributor. A majority of P&T committee members shall be
11 practicing physicians, practicing pharmacists, or both, and shall be
12 licensed in Oklahoma;
13 2. A health insurer shall require any member of the P&T
14 committee to disclose any compensation or funding from a
15 pharmaceutical manufacturer, developer, labeler, wholesaler or
16 distributor. Such P&T committee member shall be recused from voting
17 on any product manufactured or sold by such pharmaceutical
18 manufacturer, developer, labeler, wholesaler or distributor. P&T
19 committee members shall practice in various clinical specialties
20 that adequately represent the needs of health plan enrollees, and
21 there shall be an adequate number of high-volume specialists and
22 specialists treating rare and orphan diseases;
23 3. The P&T committee shall meet no less frequently than on a
24 quarterly basis;
Req. No. 11292 Page 20
1 4. P&T committee formulary development shall be conducted
2 pursuant to a transparent process, and formulary decisions and
3 rationale shall be documented in writing, with any records and
4 documents relating to the process available upon request to the
5 health plan, subject to the conditions in subsection C of this
6 section. In the case of P&T committee decisions that relate to
7 Medicaid managed care organizations' prescription drug coverage
8 policies, if the P&T committee relies upon any third party to
9 provide cost-effectiveness analysis or research, the P&T committee
10 shall:
11 a. disclose to the health benefit plan, the state, and
12 the general public the name of the relevant third
13 party, and
14 b. provide a process through which patients and providers
15 potentially impacted by the third party's analysis or
16 research may provide input to the P&T committee;
17 5. Specialists with current clinical expertise who actively
18 treat patients in a specific therapeutic area, and the specific
19 conditions within a therapeutic area, shall participate in formulary
20 decisions regarding each therapeutic area and specific condition;
21 6. The P&T committee shall base its clinical decisions on the
22 strength of scientific evidence, standards of practice, and
23 nationally accepted treatment guidelines;
24
Req. No. 11292 Page 21
1 7. The P&T committee shall consider whether a particular drug
2 has a clinically meaningful therapeutic advantage over other drugs
3 in terms of safety, effectiveness, or clinical outcome for patient
4 populations who may be treated with the drug;
5 8. The P&T committee shall evaluate and analyze treatment
6 protocols and procedures related to the health plan's formulary at
7 least annually;
8 9. The P&T committee shall review formulary management
9 activities, including exceptions and appeals processes, prior
10 authorization, step therapy, quantity limits, generic substitutions,
11 therapeutic interchange, and other drug utilization management
12 activities for clinical appropriateness and consistency with
13 industry standards and patient and provider organization guidelines;
14 10. The P&T committee shall annually review and provide a
15 written report to the pharmacy benefits manager on:
16 a. the percentage of prescription drugs on formulary
17 subject to each of the types of utilization management
18 described in paragraph 9 of this subsection,
19 b. rates of adherence and nonadherence to medicines by
20 therapeutic area,
21 c. rates of abandonment of medicines by therapeutic area,
22 d. recommendations for improved adherence and reduced
23 abandonment,
24
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1 e. recommendations for improvement in formulary
2 management practices consistent with patient and
3 provider organization and other clinical guidelines;
4 provided that the report shall be subject to the
5 conditions in subsection C of this section;
6 11. The P&T committee shall review and make a formulary
7 decision on a new U.S. Food and Drug Administration approved drug
8 within ninety (90) days of such drug's approval, or shall provide a
9 clinical justification if this time frame is not met;
10 12. The P&T committee shall review procedures for medical
11 review of, and transitioning new plan enrollees to, appropriate
12 formulary alternatives to ensure that such procedures appropriately
13 address situations involving enrollees stabilized on drugs that are
14 not on the health plan formulary (or that are on formulary but
15 subject to prior authorization, step therapy, or other utilization
16 management requirements).
17 C. The health insurer, its agents, including pharmacy benefits
18 managers, and the Department shall not publish or otherwise disclose
19 any confidential, proprietary information, including, but not
20 limited to, any information that would reveal the identity of a
21 specific health plan, the prices charged for a specific drug or
22 class of drugs, the amount of any rebates provided for a specific
23 drug or class of drugs, the manufacturer, or that would otherwise
24 have the potential to compromise the financial, competitive, or
Req. No. 11292 Page 23
1 proprietary nature of the information. Any such information shall
2 be protected from disclosure as confidential and proprietary
3 information, is not a public record as defined in the Oklahoma Open
4 Records Act, Section 24A.1 et seq. of Title 51 of the Oklahoma
5 Statutes, and shall not be disclosed directly or indirectly. A
6 health insurer shall impose the confidentiality protections of this
7 section on any vendor or downstream third party that performs health
8 care or administrative services on behalf of the pharmacy benefits
9 manager that may receive or have access to rebate information.
10 SECTION 7. AMENDATORY 59 O.S. 2021, Section 357, as
11 amended by Section 4, Chapter 332, O.S.L. 2024 (59 O.S. Supp. 2024,
12 Section 357), is amended to read as follows:
13 Section 357. A. As used in Sections 357 through 360 of this
14 title:
15 1. "Covered entity" means a nonprofit hospital or medical
16 service organization, for-profit hospital or medical service
17 organization, insurer, health benefit plan, health maintenance
18 organization, health program administered by the state in the
19 capacity of providing health coverage, or an employer, labor union,
20 or other group of persons that provides health coverage to persons
21 in this state. This term does not include a health benefit plan
22 that provides coverage only for accidental injury, specified
23 disease, hospital indemnity, disability income, or other limited
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1 benefit health insurance policies and contracts that do not include
2 prescription drug coverage;
3 2. "Covered individual" means a member, participant, enrollee,
4 contract holder or policy holder or beneficiary of a covered entity
5 who is provided health coverage by the covered entity. A covered
6 individual includes any dependent or other person provided health
7 coverage through a policy, contract or plan for a covered
8 individual;
9 3. "Department" means the Insurance Department;
10 4. "Maximum allowable cost", "MAC", or "MAC list" means the
11 list of drug products delineating the maximum per-unit reimbursement
12 for multiple-source prescription drugs, medical product, or device;
13 5. "Multisource drug product reimbursement" (reimbursement)
14 means the total amount paid to a pharmacy inclusive of any reduction
15 in payment to the pharmacy, excluding prescription dispense fees;
16 6. "Office" means the Office of the Attorney General;
17 7. "Pharmacy benefits management" means a service provided to
18 covered entities to facilitate the provision of prescription drug
19 benefits to covered individuals within the state, including
20 negotiating pricing and other terms with drug manufacturers and
21 providers. Pharmacy benefits management may include any or all of
22 the following services:
23 a. claims processing, performance of drug utilization
24 review, processing of drug prior authorization
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1 requests, retail network management and payment of
2 claims to pharmacies for prescription drugs dispensed
3 to covered individuals,
4 b. clinical formulary development and management
5 services, or
6 c. rebate contracting and administration,
7 d. adjudication of appeals and grievances related to the
8 prescription drug benefit, or
9 e. controlling the cost of prescription drugs;
10 8. "Pharmacy benefits manager" or "PBM" means a person,
11 business, or other entity that, either directly or through an
12 intermediary, performs pharmacy benefits management. The term shall
13 include a person or entity acting on behalf of a PBM in a
14 contractual or employment relationship in the performance of
15 pharmacy benefits management for a managed care company, nonprofit
16 hospital, medical service organization, insurance company, third-
17 party payor, or a health program administered by an agency or
18 department of this state. PBM does not include a Pharmacy Services
19 Administrative Organization;
20 9. "Plan sponsor" means the employers, insurance companies,
21 unions and health maintenance organizations or any other entity
22 responsible for establishing, maintaining, or administering a health
23 benefit plan on behalf of covered individuals; and
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1 10. "Provider" means a pharmacy licensed by the State Board of
2 Pharmacy, or an agent or representative of a pharmacy, including,
3 but not limited to, the pharmacy's contracting agent, which
4 dispenses prescription drugs or devices to covered individuals.
5 B. Nothing in the definition of pharmacy benefits management or
6 pharmacy benefits manager in the Patient's Right to Pharmacy Choice
7 Act, Pharmacy Audit Integrity Act, or Sections 357 through 360 of
8 this title shall deem an employer a "pharmacy benefits manager" of
9 its own self-funded health benefit plan, except, to the extent
10 permitted by applicable law, where the employer, without the
11 utilization of a third party and unrelated to the employer's own
12 pharmacy:
13 a. negotiates directly with drug manufacturers,
14 b. processes claims on behalf of its members, or
15 c. manages its own retail network of pharmacies.
16 SECTION 8. AMENDATORY 59 O.S. 2021, Section 358, as
17 amended by Section 5, Chapter 332, O.S.L. 2024 (59 O.S. Supp. 2024,
18 Section 358), is amended to read as follows:
19 Section 358. A. In order to provide pharmacy benefits
20 management or any of the services included under the definition of
21 pharmacy benefits management in this state, a pharmacy benefits
22 manager or any entity acting as one in a contractual or employment
23 relationship for a covered entity shall first obtain a license from
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1 the Insurance Department, and the Department may charge a fee for
2 such licensure.
3 B. The Department shall establish, by regulation, licensure
4 procedures, required disclosures for pharmacy benefits managers
5 (PBMs) and other rules as may be necessary for carrying out and
6 enforcing the provisions of this title. The licensure procedures
7 shall, at a minimum, include the completion of an application form
8 that shall include the name and address of an agent for service of
9 process, the payment of a requisite fee, and evidence of the
10 procurement of a surety bond the following:
11 1. The name, address, and telephone contact number of the PBM;
12 2. The name and address of the PBM's agent for service of
13 process in the state;
14 3. The name and address of each person with management or
15 control over the PBM;
16 4. Evidence of the procurement of a surety bond;
17 5. The name and address of each person with a beneficial
18 ownership interest in the PBM;
19 6. In the case of a PBM applicant that is a partnership or
20 other unincorporated association, limited liability corporation, or
21 corporation, and has five or more partners, members, or
22 stockholders:
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1 a. the applicant shall specify its legal structure and
2 the total number of partners, members, or
3 stockholders,
4 b. the applicant shall specify the name, address, usual
5 occupation, and professional qualifications of the
6 five partners, members, or stockholders with the five
7 largest ownership interests in the PBM, and
8 c. the applicant shall agree that, upon request by the
9 Department, it shall furnish the Department with
10 information regarding the name, address, usual
11 occupation, and professional qualifications of any
12 other partners, members, or stockholders;
13 7. A signed statement indicating that the PBM has not been
14 convicted of a felony and has not violated any of the requirements
15 of the Oklahoma Pharmacy Act and the Patient's Right to Pharmacy
16 Choice Act, or, if the applicant cannot provide such a statement, a
17 signed statement describing all relevant convictions or violations;
18 and
19 8. Any other information the Commissioner deems necessary to
20 review.
21 C. The Department or the Office of the Attorney General may
22 subpoena witnesses and information. Its compliance officers may
23 take and copy records for investigative use and prosecutions.
24 Nothing in this subsection shall limit the Office of the Attorney
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1 General from using its investigative demand authority to investigate
2 and prosecute violations of the law.
3 D. The Department may suspend, revoke or refuse to issue or
4 renew a license for noncompliance with any of the provisions hereby
5 established or with the rules promulgated by the Department; for
6 conduct likely to mislead, deceive or defraud the public or the
7 Department; for unfair or deceptive business practices or for
8 nonpayment of an application or renewal fee or fine. The Department
9 may also levy administrative fines for each count of which a PBM has
10 been convicted in a Department hearing.
11 E. 1. The Office of the Attorney General, after notice and
12 opportunity for hearing, may instruct the Insurance Commissioner
13 that the PBM's license be censured, suspended, or revoked for
14 conduct likely to mislead, deceive, or defraud the public or the
15 State of Oklahoma; or for unfair or deceptive business practices, or
16 for any violation of the Patient's Right to Pharmacy Choice Act, the
17 Pharmacy Audit Integrity Act, or Sections 357 through 360 of this
18 title. The Office of the Attorney General may also levy
19 administrative fines for each count of which a PBM has been
20 convicted following a hearing before the Attorney General. If the
21 Attorney General makes such instruction, the Commissioner shall
22 enforce the instructed action within thirty (30) calendar days.
23 2. In addition to or in lieu of any censure, suspension, or
24 revocation of a license by the Commissioner, the Attorney General
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1 may levy a civil or administrative fine of not less than One Hundred
2 Dollars ($100.00) and not greater than Ten Thousand Dollars
3 ($10,000.00) for each violation of this subsection and/or assess any
4 other penalty or remedy authorized by this section. For purposes of
5 this section, each day a PBM fails to comply with an investigation
6 or inquiry may be considered a separate violation.
7 F. The Attorney General may promulgate rules to implement the
8 provisions of Sections 357 through 360 of this title.
9 SECTION 9. This act shall become effective November 1, 2025.
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Req. No. 11292 Page 31Every fact on this page links to its source, starting with the official bill record.