Rep. Norm Thurston — Voting Record

Bill

Number

H.B. 257 (2025GS)

Sponsor

Rep. Thurston, Norman K  (Thurston’s own bill)

Final action

Governor Signed 3/27/2025

Outcome

Became law — signed by Gov. Spencer J. Cox

Summary

What it does

• This bill:
• defines terms;
• requires the commissioner of the Insurance Department to assist in creating a form if requested;
• requires a health benefit plan to ensure pharmaceutical rebates are used for certain purposes; and
• requires a pharmacy benefit manager to offer certain options to self-funded health benefit plans.

Every vote on this bill

Bill text

18
31A-2-212
31A-22-643
31A-46-102
31A-46-311
0
Pharmacy Benefit Amendments
2025 GENERAL SESSION
STATE OF UTAH
Chief Sponsor: Norman K Thurston
Senate Sponsor: Evan J. Vickers
LONG TITLE
General Description:
This bill amends provisions related to health insurance pharmacy benefits.
Highlighted Provisions:
This bill:
 defines terms;
requires the commissioner of the Insurance Department to assist in creating a form if 
requested;
requires a health benefit plan to ensure pharmaceutical rebates are used for certain 
purposes; and
requires a pharmacy benefit manager to offer certain options to self-funded health benefit 
plans.
Money Appropriated in this Bill:
None
Other Special Clauses:
None
Utah Code Sections Affected:
AMENDS:
31A-2-212
, as last amended by Laws of Utah 2020, Chapter 32
31A-22-643
, as enacted by Laws of Utah 2014, Chapter 111
31A-46-102
, as last amended by Laws of Utah 2020, Chapters 198, 275 and 372
ENACTS:
31A-46-311
, Utah Code Annotated 1953
Be it enacted by the Legislature of the state of Utah:
Section 1, Section 
31A-2-212
 is amended to read:
31A-2-212
. Miscellaneous duties.
(1)
Upon issuance of an order limiting, suspending, or revoking a person's authority to do 
business in Utah, and when the commissioner begins a proceeding against an insurer 
under Chapter 27a, Insurer Receivership Act, the commissioner:
(a)
shall notify by mail the producers of the person or insurer of whom the commissioner 
has record; and
(b)
may publish notice of the order or proceeding in any manner the commissioner 
considers necessary to protect the rights of the public.
(2)
(a)
When required for evidence in a legal proceeding, the commissioner shall furnish 
a certificate of authority of a licensee to transact the business of insurance in Utah on 
any particular date.
(b)
The court or other officer shall receive a certificate of authority described in this 
Subsection (2) in lieu of the commissioner's testimony.
(3)
(a)
On the request of an insurer authorized to do a surety business, the commissioner 
shall furnish a copy of the insurer's certificate of authority to a designated public 
officer in this state who requires that certificate of authority before accepting a bond.
(b)
The public officer described in Subsection (3)(a) shall file the certificate of authority 
furnished under Subsection (3)(a).
(c)
After a certified copy of a certificate of authority is furnished to a public officer, it is 
not necessary, while the certificate of authority remains effective, to attach a copy of 
it to any instrument of suretyship filed with that public officer.
(d)
Whenever the commissioner revokes the certificate of authority or begins a 
proceeding under Chapter 27a, Insurer Receivership Act, against an insurer 
authorized to do a surety business, the commissioner shall immediately give notice of 
that action to each public officer who is sent a certified copy under this Subsection (3).
(4)
(a)
The commissioner shall immediately notify every judge and clerk of the courts of 
record in the state when:
(i)
an authorized insurer doing a surety business:
(A)
files a petition for receivership; or
(B)
is in receivership; or
(ii)
the commissioner has reason to believe that the authorized insurer doing surety 
business:
(A)
is in financial difficulty; or
(B)
has unreasonably failed to carry out any of the authorized insurer's contracts.
(b)
Upon the receipt of the notice required by this Subsection (4), it is the duty of the 
judges and clerks to notify and require a person that files with the court a bond on 
which the authorized insurer doing surety business is surety to immediately file a new 
bond with a new surety.
(5)
(a)
The commissioner shall require an insurer that issues, sells, renews, or offers 
health insurance coverage in this state to comply with PPACA and administrative 
rules adopted by the commissioner related to regulation of health benefit plans, 
including:
(i)
lifetime and annual limits;
(ii)
prohibition of rescissions;
(iii)
coverage of preventive health services;
(iv)
coverage for a child or dependent;
(v)
pre-existing condition limitations;
(vi)
insurer transparency of consumer information including plan disclosures, 
uniform coverage documents, and standard definitions;
(vii)
premium rate reviews;
(viii)
essential health benefits;
(ix)
provider choice;
(x)
waiting periods;
(xi)
appeals processes;
(xii)
rating restrictions;
(xiii)
uniform applications and notice provisions;
(xiv)
certification and regulation of qualified health plans; and
(xv)
network adequacy standards.
(b)
The commissioner shall preserve state control over:
(i)
the health insurance market in the state;
(ii)
qualified health plans offered in the state; and
(iii)
the conduct of navigators, producers, and in-person assisters operating in the 
state.
(6)
If requested by an association that represents pharmacies or pharmacists, the 
commissioner shall assist the association in developing a form that outlines a pharmacy's 
rights under state and federal law related to pharmacy benefits, pharmacy benefit 
managers, and health benefit plans.
Section 2, Section 
31A-22-643
 is amended to read:
31A-22-643
. Prescription synchronization -- Copay and dispensing fee 
restrictions -- Rebate requirements -- Pharmacy networks.
(1)
For purposes of this section:
(a)
"Administrative fee" means the same as that term is defined in Section 
31A-46-102
.
(b)
"Copay" means the copay normally charged for a prescription drug.
(b)
(c)
"Health insurer" means an insurer, as defined in Subsection 
31A-22-634
(1).
(c)
(d)
"Network pharmacy" means a pharmacy included in a health insurance plan's 
network of pharmacy providers.
(e)
"Pharmacy benefit manager" means the same as that term is defined in Section 
31A-46-102
.
(d)
(f)
"Prescription drug" means a prescription drug, as defined in Section 
58-17b-102
, 
that is prescribed for a chronic condition.
(g)
"Rebate" means the same as that term is defined in Section 
31A-46-102
.
(h)
"Standard rebate amount" means a rebate amount that:
(i)
is estimated and set by a health benefit plan for a drug product;
(ii)
adjusts each quarter based on rebate underpayments or overpayments; and
(iii)
is applied when the drug product is dispensed.
(2)
A health insurance plan may not charge an amount in excess of the copay for the 
dispensing of a prescription drug in a quantity less than the prescribed amount if:
(a)
the pharmacy dispenses the prescription drug in accordance with the health insurer's 
synchronization policy; and
(b)
the prescription drug is dispensed by a network pharmacy.
(3)
A health insurance plan that includes a prescription drug benefit:
(a)
shall implement a synchronization policy for the dispensing of prescription drugs to 
the plan's enrollees; and
(b)
may not base the dispensing fee for an individual prescription on the quantity of the 
prescription drug dispensed to fill or refill the prescription unless otherwise agreed to 
by the plan and the contracted pharmacy at the time the individual requests 
synchronization.
(4)
This section applies to health benefit plans renewed or entered into on or after January 
1, 2015.
(4)
(a)
A health benefit plan shall ensure that each pharmaceutical manufacturer rebate is 
used exclusively to benefit enrollees using one or multiple of the following methods:
(i)
passing down the rebate to the point of sale to offset an enrollee's deductible or 
coinsurance;
(ii)
using the rebate to reduce premiums paid by the enrollee; or
(iii)
using the rebate to enhance enrollee health benefits.
(b)
When passing down a rebate as described in Subsection (4)(a)(i), a health benefit 
plan may:
(i)
divide the rebate between the health benefit plan and the enrollee in a manner that 
is proportional to the enrollee's payment obligation; or
(ii)
use a standard rebate amount.
(5)
A health benefit plan may not prohibit or condition participation in one pharmacy 
network on participation in another pharmacy network.
(6)
Subsections (4) and (5) apply to a health benefit plan renewed or entered into on or after 
July 1, 2026.
Section 3, Section 
31A-46-102
 is amended to read:
31A-46-102
. Definitions.
As used in this chapter:
(1)
"340B drug" means a drug purchased through the 340B drug discount program by a 
340B entity.
(2)
"340B drug discount program" means the 340B drug discount program described in 42 
U.S.C. Sec. 256b.
(3)
"340B entity" means:
(a)
an entity participating in the 340B drug discount program;
(b)
a pharmacy of an entity participating in the 340B drug discount program; or
(c)
a pharmacy contracting with an entity participating in the 340B drug discount 
program to dispense drugs purchased through the 340B drug discount program.
(4)
"Administrative fee" means any payment, other than a rebate, that a pharmaceutical 
manufacturer makes directly or indirectly to a pharmacy benefit manager.
(5)
"Allowable claim amount" means the amount paid by an insurer under the customer's 
health benefit plan.
(6)
"Contracting insurer" means an insurer with whom a pharmacy benefit manager 
contracts to provide a pharmacy benefit management service.
(7)
"Cost share" means the amount paid by an insured customer under the customer's health 
benefit plan.
(8)
"Device" means the same as that term is defined in Section 
58-17b-102
.
(9)
(8)
"Direct or indirect remuneration" means any adjustment in the total compensation:
(a)
received by a pharmacy from a pharmacy benefit manager for the sale of a drug, 
device, or other product or service; and
(b)
that is determined after the sale of the product or service.
(10)
(9)
"Dispense" means the same as that term is defined in Section 
58-17b-102
.
(11)
(10)
"Drug" means the same as that term is defined in Section 
58-17b-102
.
(12)
(11)
"Insurer" means the same as that term is defined in Section 
31A-22-636
.
(13)
(12)
"Maximum allowable cost" means:
(a)
a maximum reimbursement amount for a group of pharmaceutically and 
therapeutically equivalent drugs; or
(b)
any similar reimbursement amount that is used by a pharmacy benefit manager to 
reimburse pharmacies for multiple source drugs.
(14)
(13)
"Medicaid program" means the same as that term is defined in Section 
26B-3-101
.
(15)
(14)
"Obsolete" means a product that may be listed in national drug pricing 
compendia but is no longer available to be dispensed based on the expiration date of the 
last lot manufactured.
(16)
(15)
"Patient counseling" means the same as that term is defined in Section 
58-17b-102
.
(17)
(16)
"Pharmaceutical facility" means the same as that term is defined in Section 
58-17b-102
.
(18)
(17)
"Pharmaceutical manufacturer" means a pharmaceutical facility that 
manufactures prescription drugs.
(19)
(18)
"Pharmacist" means the same as that term is defined in Section 
58-17b-102
.
(20)
(19)
"Pharmacy" means the same as that term is defined in Section 
58-17b-102
.
(21)
(20)
"Pharmacy benefits management service" means any of the following services 
provided to a health benefit plan, or to a participant of a health benefit plan:
(a)
negotiating the amount to be paid by a health benefit plan for a prescription drug; or
(b)
administering or managing a prescription drug benefit provided by the health benefit 
plan for the benefit of a participant of the health benefit plan, including administering 
or managing:
(i)
an out-of-state mail service pharmacy;
(ii)
a specialty pharmacy;
(iii)
claims processing;
(iv)
payment of a claim;
(v)
retail network management;
(vi)
clinical formulary development;
(vii)
clinical formulary management services;
(viii)
rebate contracting;
(ix)
rebate administration;
(x)
a participant compliance program;
(xi)
a therapeutic intervention program;
(xii)
a disease management program; or
(xiii)
a service that is similar to, or related to, a service described in Subsection 
(21)(a) or 
(21)(b)(i) through (xii).
(20)(a) or this Subsection (20)(b).
(22)
(21)
"Pharmacy benefit manager" means a person licensed under this chapter to 
provide a pharmacy benefits management service.
(23)
(22)
"Pharmacy service" means a product, good, or service provided to an individual 
by a pharmacy or pharmacist.
(24)
(23)
"Pharmacy services administration organization" means an entity that contracts 
with a pharmacy to assist with third-party payer interactions and administrative services 
related to third-party payer interactions, including:
(a)
contracting with a pharmacy benefit manager on behalf of the pharmacy; and
(b)
managing a pharmacy's claims payments from third-party payers.
(25)
(24)
"Pharmacy service entity" means:
(a)
a pharmacy services administration organization; or
(b)
a pharmacy benefit manager.
(26)
(25)
"Prescription device" means the same as that term is defined in Section 
58-17b-102
.
(27)
(26)
"Prescription drug" means the same as that term is defined in Section 
58-17b-102
.
(28)
(27)
(a)
"Rebate" means a refund, discount, or other price concession that is paid by 
a pharmaceutical manufacturer to a pharmacy benefit manager based on a 
prescription drug's utilization or effectiveness.
(b)
"Rebate" does not include an administrative fee.
(29)
(28)
(a)
"Reimbursement report" means a report on the adjustment in total 
compensation for a claim.
(b)
"Reimbursement report" does not include a report on adjustments made pursuant to a 
pharmacy audit or reprocessing.
(30)
(29)
"Retail pharmacy" means the same as that term is defined in Section 
58-17b-102
.
(31)
(30)
"Sale" means a prescription drug or prescription device claim covered by a 
health benefit plan.
(31)
"Spread pricing" means the practice in which a pharmacy benefit manager charges a 
health benefit plan a different amount for pharmacist services than the amount the 
pharmacy benefit manager reimburses a pharmacy for pharmacist services.
(32)
"Wholesale acquisition cost" means the same as that term is defined in 42 U.S.C. Sec. 
1395w-3a.
Section 4, Section 
31A-46-311
 is enacted to read:
31A-46-311
. Options for self-funded health benefit plans.
A pharmacy benefit manager shall offer to a self-funded health benefit plan, as an option 
for the self-funded health benefit plan's design, pharmacy benefit management services that:
(1)
comply with the provisions of Subsections 
31A-22-643
(4) and (5), collectively and 
individually; and
(2)
do not include spread pricing.
Section 5. 
Effective Date.
This bill takes effect on 
May 7, 2025
.
3-11-25 3:01 PM