Pharmacy benefit management firm payments - retroactive reduction prohibited - enforcement - rules - dispensing fees - definitions

10-16-122.3. Pharmacy benefit management firm payments - retroactive reduction prohibited - enforcement - rules - dispensing fees - definitions. (1) (a) A pharmacy benefit management firm shall not reimburse a pharmacy in an amount less than the amount that the pharmacy benefit management firm reimburses any affiliate for the same pharmacy services. (b) This subsection (1) does not prohibit a pharmacy benefit management firm from reimbursing an affiliate for satisfying the terms of a performance-based contract. (1.5) [Editor's note: Subsection (1.5) is effective January 1, 2026.] On and after January 1, 2026, a pharmacy benefit management firm shall reimburse a rural independent pharmacy for a prescription drug in an amount not less than the national average drug acquisition cost for the dispensed prescription drug ingredients and a dispensing fee. If the national average drug acquisition cost is not available at the time a prescription drug is administered or dispensed, a pharmacy benefit management firm shall not reimburse in an amount that is less than the wholesale acquisition cost of the prescription drug. (2) (a) A contract or agreement, including a performance-based or value-based contract or agreement, between a pharmacy benefit management firm and a pharmacy or a pharmacy services administrative organization with respect to prescription drug benefits administered or managed by the pharmacy benefit management firm must provide that after the date the pharmacy benefit management firm receives a clean claim submitted by a pharmacy, the pharmacy benefit management firm shall not retroactively reduce payment on the claim after the point of sale except as the result of an audit conducted in accordance with section 10-16-122.5. (b) Nothing in this subsection (2) prohibits a pharmacy benefit management firm from retroactively increasing a payment to a pharmacy pursuant to a written agreement between the pharmacy benefit management firm and the pharmacy or making adjustments to claims in the case of a clerical error. (3) Each carrier that contracts with a pharmacy benefit management firm to manage or administer prescription drug benefits on the carrier's behalf shall include in a new, amended, or renewed contract with the pharmacy benefit management firm a requirement that the pharmacy benefit management firm comply with this section. The carrier shall annually audit the pharmacy benefit management firm to monitor and ensure compliance with this section. (4) The division may promulgate rules to implement and enforce this section, including rules to establish the manner in which carriers and pharmacy benefit management firms are required to show compliance with this section. (5) This section applies to contracts and agreements between pharmacy benefit management firms and pharmacies or pharmacy services administrative organizations in effect on or after January 1, 2021. (5.5) With regard to the requirements of this section applicable to pharmacy benefit management firms, the commissioner has the authority to enforce this section and to impose a penalty or other remedy against a pharmacy benefit management firm that fails to comply with this section. (6) As used in this section: (a) Affiliate means a pharmacy that directly or indirectly, through one or more intermediaries, owns or controls, is owned or controlled by, or is under common ownership or control with a pharmacy benefit management firm. (b) Clean claim means a claim that has no defect or impropriety, including any lack of required substantiating documentation, or particular circumstance requiring special treatment that prevents timely payment from being made on the claim. Clean claim does not include a claim based on fraud, waste, or abuse. (b.3) [Editor's note: Subsection (6)(b.3) is effective January 1, 2026.] Dispensing fee means the reimbursement amount for costs associated with filling a prescription, as published for rural pharmacies in 10 CCR 2505-10 sec. 8.800.13.M, as specified in the version of the rule adopted on July 12, 2024. On January 1, 2027, and on January 1 of every year thereafter, a pharmacy benefit management firm shall increase the amount of the dispensing fee by one percent to account for inflation. (c) Pharmacy means an in-state or nonresident prescription drug outlet, as defined in section 12-280-103 (43); an other outlet, as defined in section 12-280-103 (32); a hospital satellite pharmacy, as defined in section 12-280-103 (20); or other setting, including a practitioner's office or clinic, where a practitioner, as defined in section 12-280-103 (40), dispenses prescription drugs to patients as authorized by section 12-280-120 (6). Source: L. 2020: Entire section added, (HB 20-1078), ch. 98, p. 381, � 1, effective September 14. L. 2023: (4) amended and (5.5) added, (HB 23-1227), ch. 160, p. 695, � 2, effective August 7. L. 2025: (1.5) and (6)(b.3) added, (HB 25-1222), ch. 259, p. 1328, � 4, effective January 1, 2026. Editor's note: Section 8(2) of chapter 259 (HB 25-1222), Session Laws of Colorado 2025, provides that the act changing this section applies to conduct occurring on or after January 1, 2026. Cross references: For the legislative declaration in HB 25-1222, see section 1 of chapter 259, Session Laws of Colorado 2025.