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WEST VIRGINIA LEGISLATURE
2026 REGULAR SESSION
ENROLLED
Committee Substitute
for
House Bill 5430
BY DELEGATES WORRELL AND PETITTO
[Passed March 13, 2026; in effect from passage]
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1 AN ACT to amend and reenact §5-16-9, §33-51-3, and §33-51-9 of the Code of West Virginia,
2 1931, as amended; and to amend the code by adding two new sections, designated §9-
3 5-34 and §33-51-14, relating to pharmaceutical benefits; making the Public Employees
4 Insurance Agency subject the Pharmacy audit Integrity Act; providing exceptions;
5 providing specific provisions shall not be applied to conflict with Medicare; requiring
6 competitive bid solicitation for cost containment vendor; setting forth terms for cost
7 containment vendor contract; requiring the Medicaid program to establish a time limited
8 pilot program; defining terms; limiting amounts charged by pharmacy benefit managers;
9 addressing Public Employees Insurance Agency rebate; prohibiting certain pharmacy
10 benefit manager ownership structures; requiring a study; and requiring a report.
Be it enacted by the Legislature of West Virginia:
CHAPTER 5. GENERAL POWERS AND AUTHORITY OF THE
GOVERNOR, SECRETARY OF STATE AND ATTORNEY GENERAL;
BOARD OF PUBLIC WORKS; MISCELLANEOUS AGENCIES,
COMMISSIONS, OFFICES, PROGRAMS, ETC.
ARTICLE 16. WEST VIRGINIA PUBLIC EMPLOYEES INSURANCE ACT.
§5-16-9. Authorization to execute contracts.
1 (a) The director is given exclusive authorization to execute such contract or contracts as
2 are necessary to carry out the provisions of this article.
3 (b) The provisions of §5A-3-1 et seq. of this code, relating to the Division of Purchasing of
4 the Department of Finance and Administration, shall not apply to any contracts for any insurance
5 coverage or professional services authorized to be executed under the provisions of this article.
6 Before entering into any contract for any insurance coverage, as authorized in this article, the
7 director shall invite competent bids from all qualified and licensed insurance companies or carriers
8 that may wish to offer plans for the insurance coverage desired. The director shall negotiate and
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9 contract directly with health care providers and other entities, organizations, and vendors in order
10 to secure competitive premiums, prices, and other financial advantages. The director shall deal
11 directly with insurers or health care providers and other entities, organizations, and vendors in
12 presenting specifications and receiving quotations for bid purposes. No commission or finder’s
13 fee, or any combination thereof, shall be paid to any individual or agent: Provided, That this shall
14 not preclude an underwriting insurance company or companies, at their own expense, from
15 appointing a licensed resident agent within this state to service the companies’ contracts awarded
16 under the provisions of this article. Commissions reasonably related to actual service rendered
17 for the agent or agents may be paid by the underwriting company or companies. In no event shall
18 payment be made to any agent or agents when no actual services are rendered or performed.
19 The director shall award the contract or contracts on a competitive basis. In awarding the contract
20 or contracts, the director shall consider the experience of the offering agency, corporation,
21 insurance company, or service organization in the group hospital and surgical insurance field,
22 group major medical insurance field, group prescription drug field, and group life and accidental
23 death insurance field, and its facilities for the handling of claims. In evaluating these factors, the
24 director may employ the services of impartial, professional insurance analysts or actuaries, or
25 both. Any contract executed by the director with a selected carrier shall be a contract to govern
26 all eligible employees subject to the provisions of this article. Nothing contained in this article shall
27 prohibit any insurance carrier from soliciting employees covered hereunder to purchase additional
28 hospital and surgical, major medical, or life and accidental death insurance coverage.
29 (c) The director may authorize the carrier with whom a primary contract is executed to
30 reinsure portions of the contract with other carriers which elect to be a reinsurer and who are
31 legally qualified to enter into a reinsurance agreement under the laws of this state.
32 (d) Each employee who is covered under any contract or contracts shall receive a
33 statement of benefits to which the employee, his or her spouse, and his or her dependents are
34 entitled under the contract, setting forth the information as to whom the benefits are payable, to
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35 whom claims shall be submitted, and a summary of the provisions of the contract or contracts as
36 they affect the employee, his or her spouse, and his or her dependents.
37 (e) The director may at the end of any contract period discontinue any contract or contracts
38 it has executed with any carrier and replace the same with a contract or contracts with any other
39 carrier or carriers meeting the requirements of this article.
40 (f) The director shall include language in all contracts for pharmacy benefits management,
41 as defined by §33-51-3 of this code, requiring the pharmacy benefit manager to report quarterly
42 to the agency the following:
43 (1) The overall total amount charged to the agency for all claims processed by the
44 pharmacy benefit manager during the quarter;
45 (2) The overall total amount of reimbursements paid to pharmacy providers during the
46 quarter;
47 (3) The overall total number of claims in which the pharmacy benefits manager reimbursed
48 a pharmacy provider for less than the amount charged to the agency for all claims processed by
49 the pharmacy benefit manager during the quarter; and
50 (4) For all pharmacy claims, the total amount paid to the pharmacy provider per claim,
51 including, but not limited to, the following:
52 (A) The cost of drug reimbursement;
53 (B) Dispensing fees;
54 (C) Copayments;
55 (D) The amount charged to the agency for each claim by the pharmacy benefit manager;
56 (E) Date of service;
57 (F) NDC-11;
58 (G) Drug name;
59 (H) Drug strength;
60 (I) Quantity;
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61 (J) Days of therapy;
62 (K) Rx count;
63 (L) Mail/retail code;
64 (M) Brand/generic indicator;
65 (N) Specialty drug indicator;
66 (O) Compound indicator;
67 (P) Formulary indicator;
68 (Q) Gross cost;
69 (R) Member cost;
70 (S) Plan cost;
71 (T) Dispense as written;
72 (U) Pharmacy NPI number;
73 (V) Pharmacy Claim ID;
74 (W) Prescriber NPI number;
75 (X) Pharmacy name; and
76 (Y) Ingredient cost.
77 In the event there is a difference between the amount for any pharmacy claim paid to the
78 pharmacy provider and the amount reimbursed to the agency, the pharmacy benefit manager
79 shall report an itemization of all administrative fees, rebates, or processing charges associated
80 with the claim. The director shall provide an annual report to the Joint Committee on Health
81 detailing the information required by this section, including any difference or spread between the
82 overall amount paid by pharmacy benefit managers to the pharmacy providers and the overall
83 amount charged to the agency for each claim by the pharmacy benefit manager. To the extent
84 necessary, the director shall use aggregated, nonproprietary data only: Provided, That the director
85 must provide a clear and concise summary of the total amounts charged to the agency and
86 reimbursed to pharmacy providers on an annual basis.
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87 (g) If the information required herein is not provided, the agency may terminate the
88 contract with the pharmacy benefit manager and the Office of the Insurance Commissioner shall
89 discipline the pharmacy benefit manager as provided in §33-51-8(e) of this code.
90 (h) The Public Employees Insurance Agency shall contract with networks to provide care
91 to its members out of state.
92 (i) The Public Employees Insurance Agency shall require each of the following in its
93 requests for proposals and contracts with a pharmacy benefit manager:
94 (1) The pharmacy benefit manager shall disclose all information and data related to
95 contracting, reimbursement, networks, rebates, fees, and any other information and data
96 requested by the Public Employees Insurance Agency, the Legislature, and vendors for the
97 purpose of performing study and analysis.
98 (2) A pharmacy benefit manager shall not reimburse a West Virginia pharmacy or
99 pharmacist for a prescription drug or pharmacy service in an amount less than the national
100 average drug acquisition cost for a prescription drug or pharmacy service at the time the drug is
101 administered or dispensed, plus a professional dispensing fee at least equal to the professional
102 dispensing fee paid by West Virginia Medicaid for outpatient drugs. Increases to the professional
103 dispensing fee may be set by the director in accordance with this subdivision: Provided, That if
104 the national average drug acquisition cost is not available at the time a drug is administered or
105 dispensed, a pharmacy benefit manager may not reimburse a West Virginia pharmacy or
106 pharmacist in an amount that is less than the wholesale acquisition cost of the drug, as defined
107 in 42 U.S.C. § 1395w-3a(c)(6)(B), plus a dispensing fee as described in this subdivision. A West
108 Virginia pharmacy is a domestic business entity as registered with the West Virginia Secretary of
109 State. The provisions in this subdivision shall be effective for the Public Employees Insurance
110 Agency plan year beginning on July 1, 2024.
111 (j) Any contract with the Public Employees Insurance Agency for pharmacy benefits
112 management services with a pharmacy benefit manager is subject to the requirements of §33-51-
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113 1 et seq. of this code and the jurisdiction of the Office of the Insurance Commissioner: Provided,
114 That the Public Employees Insurance Agency is not subject to §33-51-9(e) of this code, and
115 nothing in this subsection shall be applied to conflict with Medicare.
116 (k) By July 1, 2026, the Public Employees Insurance Agency shall issue a competitive bid
117 solicitation for a contract with a pharmacy cost containment vendor actively engaging prescribing
118 providers by presenting information regarding cost and effectiveness, including but not limited to
119 data related to lowest net cost pharmaceutical decisions and related to reductions to
120 polypharmacy rates, if clinically reviewed and appropriate.
121 (1) The vendor managing this service shall be separate and distinct from any pharmacy
122 benefit management contract that any state agency may have in the management of the
123 pharmacy benefit.
124 (2) The vendor shall work with the Public Employees Insurance Agency to ensure that the
125 lowest net cost outcome is achieved, including calculation of drug manufacturer rebates and other
126 considerations that may be offered to the state, while not negatively impacting patient outcomes.
127 (3) Prescribing providers engaged by the vendor are not required to modify their
128 prescribing based on the information presented pursuant to this subsection but the agency retains
129 discretion to modify its drug formulary based on the vendor's recommendations.
130 (4) The pharmacy cost containment vendor contract shall contain provisions guaranteeing
131 the state an itemized monthly activity and savings report and a total net savings guarantee related
132 to all expenditures and fees for the pharmacy cost containment service.
CHAPTER 9. HUMAN SERVICES.
ARTICLE 5. MISCELLANEOUS PROVISIONS.
§9-5-34. Medicaid pharmacy benefit management; prohibited contracting; pharmacy cost
containment tool.
1 (a) For purposes of this section, "pharmacy benefit manager" and "affiliate" have the
2 meanings ascribed to those terms in §33-51-3 of this code.
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3 (b) To the extent that Medicaid has a pharmacy benefit manager managing its pharmacy
4 contract, that pharmacy benefit manager may not reimburse a pharmacy or pharmacist for a
5 prescription drug or pharmacy service in an amount less than the amount the pharmacy benefit
6 manager reimburses itself or an affiliate for the same prescription drug or pharmacy service.
7 (c) By July 1, 2026, the Medicaid program shall establish a one-year pilot program to
8 implement a pharmacy cost containment vendor. This pilot program shall focus on actively
9 engaging prescribing providers by presenting information regarding cost and effectiveness,
10 including but not limited to, data on lowest net cost pharmaceutical options and clinically
11 appropriate polypharmacy reduction strategies. This pilot program will not require Medicaid to
12 alter or violate any terms of any existing contractual agreements.
13 (1) Participation in the pilot program does not mandate changes in clinical practice, as
14 prescribing providers engaged by the vendor retain clinical discretion and are not required to
15 modify prescribing patterns based on information presented. The vendor managing this service
16 shall be separate and distinct from any pharmacy benefit management contract that any state
17 agency may have in the management of the pharmacy benefit.
18 (2) The state expenditure on the pilot program may not increase relative to the protected
19 savings generated from the pilot program. Any cost containment vendor utilized by Medicaid
20 under this pilot program must agree to the terms that reflect contractual savings to fee guarantee.
21 (3) Prescribing providers engaged by the vendor are not required to modify their
22 prescribing based on the information presented pursuant to this subsection.
23 (4) If the pilot program determines a net savings, Medicaid may enter into a contractual
24 arrangement with the vendor prior to the conclusion of the pilot program to ensure long term
25 savings are achieved.
CHAPTER 33. INSURANCE.
ARTICLE 51. PHARMACY AUDIT INTEGRITY ACT.
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§33-51-3. Definitions.
1 For purposes of this article:
2 "340B entity" means an entity participating in the federal 340B drug discount program, as
3 described in 42 U.S.C. § 256b, including its pharmacy or pharmacies, or any pharmacy or
4 pharmacies, contracted with the participating entity to dispense drugs purchased through such
5 program.
6 "Affiliate" means a pharmacy, pharmacist, or pharmacy technician which, either directly or
7 indirectly through one or more intermediaries: (1) Has an investment or ownership interest in a
8 pharmacy benefits manager licensed under this chapter; (2) Shares common ownership with a
9 pharmacy benefits manager licensed under this chapter; or (3) Has an investor or ownership
10 interest holder which is a pharmacy benefits manager licensed under this article.
11 "Auditing entity" means a person or company that performs a pharmacy audit, including a
12 pharmacy benefits manager, managed care organization, or third-party administrator.
13 "Business day" means any day of the week excluding Saturday, Sunday, and any legal
14 holiday as set forth in §2-2-1 of this code.
15 "Claim level information" means data submitted by a pharmacy or required by a payor or
16 claims processor to adjudicate a claim.
17 "Covered individual" means a member, participant, enrollee, or beneficiary of a health
18 benefit plan who is provided health coverage by a health benefit plan, including a dependent or
19 other person provided health coverage through the policy or contract of a covered individual.
20 "Extrapolation" means the practice of inferring a frequency of dollar amount of
21 overpayments, underpayments, nonvalid claims, or other errors on any portion of claims
22 submitted, based on the frequency of dollar amount of overpayments, underpayments, nonvalid
23 claims, or other errors actually measured in a sample of claims.
24 "Defined cost sharing" means a deductible payment or coinsurance amount imposed on
25 an enrollee for a covered prescription drug under the enrollee’s health plan.
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26 "Group Purchasing Organization" or "GPO" is an entity that purchases, arranges for or
27 negotiates the purchase of covered drugs, devices, biologicals, or medical supplies for a group of
28 individuals or entities, but not solely for use by the entity itself.
29 "Health benefit plan" or "health plan" means a policy, contract, certificate, or agreement
30 entered into, offered, or issued by a health carrier to provide, deliver, arrange for, pay for, or
31 reimburse any of the costs of health care services.
32 "Health care payor" or "payor" means a health insurance company, a health maintenance
33 organization, a hospital, medical, or dental corporation, a health care corporation, an entity that
34 provides, administers, or manages a self-funded health benefit plan, including a governmental
35 plan, or any other payor that provides prescription drug coverages, including a workers’
36 compensation insurer. Health care payor does not include an insurer that provides coverage
37 under a policy of casualty or property insurance.
38 "Health care provider" has the same meaning as defined in §33-41-2 of this code.
39 "Health insurance policy" means a policy, subscriber contract, certificate, or plan that
40 provides prescription drug coverage. The term includes both comprehensive and limited benefit
41 health insurance policies.
42 "Insurance commissioner" or "commissioner" has the same meaning as defined in §33-1-
43 5 of this code.
44 "List Price" means the drug manufacturer's price for a drug to wholesalers or direct
45 purchasers in the United States, not including prompt pay or other discounts, rebates, or
46 reductions in price, as reported in wholesale price guides or other publications of drug pricing
47 data.
48 "Network" means a pharmacy or group of pharmacies that agree to provide prescription
49 services to covered individuals on behalf of a health benefit plan in exchange for payment for its
50 services by a pharmacy benefits manager or pharmacy services administration organization. The
51 term includes a pharmacy that generally dispenses outpatient prescriptions to covered individuals
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52 or dispenses particular types of prescriptions, provides pharmacy services to particular types of
53 covered individuals or dispenses prescriptions in particular health care settings, including
54 networks of specialty, institutional or long-term care facilities.
55 "Maximum allowable cost" means the per unit amount that a pharmacy benefits manager
56 reimburses a pharmacist for a prescription drug, excluding dispensing fees and copayments,
57 coinsurance, or other cost-sharing charges, if any.
58 "National average drug acquisition cost" means the monthly survey of retail pharmacies
59 conducted by the federal Centers for Medicare and Medicaid Services to determine average
60 acquisition cost for Medicaid covered outpatient drugs.
61 "Nonproprietary drug" means a drug containing any quantity of any controlled substance
62 or any drug which is required by any applicable federal or state law to be dispensed only by
63 prescription.
64 "Pharmacist" means an individual licensed by the West Virginia Board of Pharmacy to
65 engage in the practice of pharmacy.
66 "Pharmacy" means any place within this state where drugs are dispensed and pharmacist
67 care is provided.
68 "Pharmacy audit" means an audit, conducted by or on behalf of an auditing entity of any
69 records of a pharmacy for prescription or nonproprietary drugs dispensed by a pharmacy to a
70 covered individual.
71 "Pharmacy benefits management" means the performance of any of the following:
72 (1) The procurement of prescription drugs at a negotiated contracted rate for dispensation
73 within the state of West Virginia to covered individuals;
74 (2) The administration or management of prescription drug benefits provided by a health
75 benefit plan for the benefit of covered individuals;
76 (3) The administration of pharmacy benefits, including:
77 (A) Operating a mail-service pharmacy;
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78 (B) Claims processing;
79 (C) Managing a retail pharmacy network;
80 (D) Paying claims to a pharmacy for prescription drugs dispensed to covered individuals
81 via retail or mail-order pharmacy;
82 (E) Developing and managing a clinical formulary including utilization management and
83 quality assurance programs;
84 (F) Rebate contracting administration;
85 (G) Operating a rebate GPO; or
86 (H) Managing a patient compliance, therapeutic intervention, and generic substitution
87 program.
88 "Pharmacy benefits manager" means a person, business, or other entity that performs
89 pharmacy benefits management for health benefit plans;
90 "Pharmacy record" means any record stored electronically or as a hard copy by a
91 pharmacy that relates to the provision of prescription or nonproprietary drugs or pharmacy
92 services or other component of pharmacist care that is included in the practice of pharmacy.
93 "Pharmacy services administration organization" means any entity that contracts with a
94 pharmacy to assist with payor interactions and that may provide a variety of other administrative
95 services, including contracting with pharmacy benefits managers on behalf of pharmacies and
96 managing pharmacies’ claims payments from payors."Point-of-sale fee" means all or a portion of
97 a drug reimbursement to a pharmacy or other dispenser withheld at the time of adjudication of a
98 claim for any reason.
99 "Rebate" means any and all payments that accrue to a pharmacy benefits manager or its
100 health plan client, directly or indirectly, from a pharmaceutical manufacturer, including, but not
101 limited to, discounts, administration fees, credits, incentives, or penalties associated directly or
102 indirectly in any way with claims administered on behalf of a health plan client. The term "rebate"
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103 does not include any discount or payment that may be provided to or made to any 340B entity
104 through such program.
105 "Rebate GPO" means a GPO that negotiates for rebates off of list price of prescription
106 drugs for its participants. The term "Rebate GPO" does not include any such entity providing
107 benefits to Medicaid, including but not limited to a state administered multi-state supplemental
108 rebate pool.
109 "Retroactive fee" means all or a portion of a drug reimbursement to a pharmacy or other
110 dispenser recouped or reduced following adjudication of a claim for any reason, except as
111 otherwise permissible as described in this article.
112 "Specialty drug" means a drug used to treat chronic and complex, or rare medical
113 conditions and requiring special handling or administration, provider care coordination, or patient
114 education that cannot be provided by a non-specialty pharmacy or pharmacist.
§33-51-9. Regulation of pharmacy benefit managers.
1 (a) A pharmacy, a pharmacist, and a pharmacy technician shall have the right to provide
2 a covered individual with information related to lower cost alternatives and cost share for the
3 covered individual to assist health care consumers in making informed decisions. Neither a
4 pharmacy, a pharmacist, nor a pharmacy technician may be penalized by a pharmacy benefit
5 manager for discussing information in this section or for selling a lower cost alternative to a
6 covered individual, if one is available, without using a health insurance policy.
7 (b) A pharmacy benefit manager may not collect from a pharmacy, a pharmacist, or a
8 pharmacy technician a cost share charged to a covered individual that exceeds the total submitted
9 charges by the pharmacy or pharmacist to the pharmacy benefit manager.
10 (c) A pharmacy benefit manager that reimburses a 340B entity for drugs that are subject
11 to an agreement under 42 U.S.C. § 256b shall not reimburse the 340B entity for pharmacy-
12 dispensed drugs at a rate lower than that paid for the same drug to pharmacies similar in
13 prescription volume that are not 340B entities, and shall not assess any fee, charge-back, or other
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14 adjustment upon the 340B entity on the basis that the 340B entity participates in the program set
15 forth in 42 U.S.C. § 256b. For purposes of this subsection, the term "other adjustment" includes
16 placing any additional requirements, restrictions, or unnecessary burdens upon the 340B entity
17 that results in administrative costs or fees to the 340B entity that are not placed upon other
18 pharmacies that do not participate in the 340B program, including affiliate pharmacies of the
19 pharmacy benefit manager, and further includes but is not limited to requiring a claim for a drug
20 to include a modifier or be processed or resubmitted to indicate that the drug is a 340B
21 drug: Provided, That nothing in this subsection shall be construed to prohibit the Medicaid
22 program or a Medicaid managed care organization as described in 42 U.S.C. § 1396b(m) from
23 preventing duplicate discounts as described in 42 U.S.C. § 256b(a)(5)(A)(i). The provisions of this
24 subsection are applicable to the West Virginia Public Employees Insurance Agency.
25 (d) With respect to a patient eligible to receive drugs subject to an agreement under 42
26 U.S.C. § 256b, a pharmacy benefit manager shall not discriminate against a 340B entity in a
27 manner that prevents or interferes with the patient’s choice to receive such drugs from the 340B
28 entity: Provided, That this section, does not apply to the state Medicaid program when Medicaid
29 is providing reimbursement for covered outpatient drugs, as that term is defined in 42 U.S.C. §
30 1396r-8(k), on a fee-for-service basis: Provided, however, That this subsection does apply to a
31 Medicaid-managed care organization as described in 42 U.S.C. § 1396b(m). For purposes of this
32 subsection, it shall be considered a discriminatory practice that prevents or interferes with a
33 patient’s choice to receive drugs at a 340B entity if a pharmacy benefit manager places additional
34 requirements, restrictions or unnecessary burdens upon a 340B entity that results in
35 administrative costs or fees to the 340B entity that are not placed upon other pharmacies that do
36 not participate in the 340B program, including affiliate pharmacies of the pharmacy benefit
37 manager or any other third-party, and further includes but is not limited to requiring a claim for a
38 drug to include a modifier or be processed or resubmitted to indicate that the drug is a 340B
39 drug: Provided further, That nothing in this subsection shall be construed to prohibit the Medicaid
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40 program or a Medicaid managed care organization as described in 42 U.S.C. § 1396b(m) from
41 preventing duplicate discounts as described in 42 U.S.C. § 256b(a)(5)(A)(i). The provisions of this
42 subsection are applicable to the West Virginia Public Employees Insurance Agency.
43 (e) A pharmacy benefit manager may not reimburse a pharmacy or pharmacist for a
44 prescription drug or pharmacy service in an amount less than the national average drug
45 acquisition cost for the prescription drug or pharmacy service at the time the drug is administered
46 or dispensed, plus a professional dispensing fee of $10.49: Provided, That if the national average
47 drug acquisition cost is not available at the time a drug is administered or dispensed, a pharmacy
48 benefit manager may not reimburse in an amount that is less than the wholesale acquisition cost
49 of the drug, as defined in 42 U.S.C. § 1395w-3a(c)(6)(B), plus a professional dispensing fee of
50 $10.49.
51 (f) A pharmacy benefit manager may not reimburse a pharmacy or pharmacist for a
52 prescription drug or pharmacy service in an amount less than the amount the pharmacy benefit
53 manager reimburses itself or an affiliate for the same prescription drug or pharmacy service.
54 (g) The commissioner may order reimbursement to an insured, pharmacy, or dispenser
55 who has incurred a monetary loss as a result of a violation of this article or legislative rules
56 implemented pursuant to this article.
57 (h)(1) Any methodologies utilized by a pharmacy benefits manager in connection with
58 reimbursement shall be filed with the commissioner at the time of initial licensure and at any time
59 thereafter that the methodology is changed by the pharmacy benefit manager for use in
60 determining maximum allowable cost appeals. The methodologies are not subject to disclosure
61 and shall be treated as confidential and exempt from disclosure under the West Virginia Freedom
62 of Information Act §29B-1-4(a)(1) of this code. The filed methodologies shall comply with the
63 provisions of §33-51-9(e) of this code, and a pharmacy benefits manager shall not enter into a
64 contract with a pharmacy that provides for reimbursement methodology not permissible under the
65 provisions of §33-51-9(e) of this code.
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66 (2) For purposes of complying with the provisions of §33-51-9(e) of this code, a pharmacy
67 benefits manager shall utilize the most recently published monthly national average drug
68 acquisition cost as a point of reference for the ingredient drug product component of a pharmacy’s
69 reimbursement for drugs appearing on the national average drug acquisition cost list.
70 (i) A pharmacy benefits manager may not:
71 (1) Discriminate in reimbursement, assess any fees or adjustments, or exclude a
72 pharmacy from the pharmacy benefit manager’s network on the basis that the pharmacy
73 dispenses drugs subject to an agreement under 42 U.S.C. § 256b; or
74 (2) Engage in any practice that:
75 (A) In any way bases pharmacy reimbursement for a drug on patient outcomes, scores,
76 or metrics. This does not prohibit pharmacy reimbursement for pharmacy care, including
77 dispensing fees from being based on patient outcomes, scores, or metrics so long as the patient
78 outcomes, scores, or metrics are disclosed to and agreed to by the pharmacy in advance;
79 (B) Includes imposing a point-of-sale fee or retroactive fee; or
80 (C) Derives any revenue from a pharmacy or insured in connection with performing
81 pharmacy benefits management services: Provided, That this may not be construed to prohibit
82 pharmacy benefits managers from processing deductibles or copayments as have been approved
83 by a covered individual’s health benefit plan.
84 (j) A pharmacy benefits manager may not charge a health care payor or health benefit
85 plan an amount greater than the national average drug acquisition cost, if available, for
86 prescription drugs. If the national average drug acquisition cost is not available, a pharmacy
87 benefits manager may not charge a health care payor or health benefit plan an amount greater
88 than the amount paid to the pharmacy: Provided, That a pharmacy benefits manager shall charge
89 a health benefit plan administered by or on behalf of the state or a political subdivision of the state,
90 the same price for a prescription drug as it pays a pharmacy for the prescription drug.
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91 (k) A covered individual’s defined cost sharing for each prescription drug shall be
92 calculated at the point of sale based on a price that is reduced by an amount equal to at least 100
93 percent of all rebates received, or to be received, by the Pharmacy Benefit Manager, the GPO,
94 or any other vendor in connection with the dispensing or administration of the prescription drug.
95 Any rebate over and above the defined cost sharing would then be passed on to the health plan
96 to reduce premiums. Nothing precludes an insurer from decreasing a covered individual’s defined
97 cost sharing by an amount greater than what is previously stated. The commissioner may propose
98 a legislative rule or by policy effectuate the provisions of this subsection: Provided, That for the
99 Public Employee Insurance Agency, 100 percent of all rebates received, or to be received, by the
100 Pharmacy Benefit Manager, the GPO, or any other vendor in connection with the dispensing or
101 administration of the prescription drug shall be passed on to the plan to reduce premiums.
102 (l) A pharmacy benefit manager may not utilize, participate in or own any part of a group
103 purchasing organization for purposes of avoiding the requirements of this article.
§33-51-14. Pharmacy dispensing fee study.
1 The Office of the Insurance Commissioner shall conduct a study of the cost to dispense
2 outpatient prescription drugs in West Virginia by soliciting data and relevant information from
3 licensed pharmacies and analyzing similar studies conducted in surrounding states within the
4 previous two years.
5 The study shall be completed and submitted to the Legislative Oversight Commission on
6 Health and Human Resources Accountability and the Joint Standing Committee on Insurance and
7 PEIA by December 1, 2026, and biennially thereafter. The study and a final report shall be
8 presented by the Office of the Insurance Commissioner to the Legislative Oversight Commission
9 on Health and Human Resources Accountability and the Joint Standing Committee on Insurance
10 and PEIA on or before January 15, 2027, and biennially thereafter.
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The Clerk of the House of Delegates and the Clerk of the Senate hereby
certify that the foregoing bill is correctly enrolled.
...............................................................
Clerk of the House of Delegates
...............................................................
Clerk of the Senate
Originated in the House of Delegates.
In effect from passage.
...............................................................
Speaker of the House of Delegates
...............................................................
President of the Senate
__________
The within is ................................................ this the...........................................
Day of ..........................................................................................................., 2026.
.............................................................
Governor
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