SB 846 - This act enacts provisions relating to insurance coverage of pharmacy services.CLINICIAN-ADMINISTERED DRUGS (Section 376.411)
This act provides that a health carrier or pharmacy benefits manager (PBM) shall not impose any penalty, impediment, differentiation, or limitation on participating providers for providing medically necessary clinician-administered drugs, regardless of whether the participating provider obtains the drugs from an in-network provider, including but not limited to refusing to approve or pay, or reimbursing less than the contracted payment amount.
Carriers and PBMs shall not impose any penalty, impediment, differentiation, or limitation on a covered person who is administered medically necessary clinician-administered drugs, regardless of whether the participating provider obtains the drugs from an in-network provider, including but not limited to: limiting coverage or benefits; requiring an additional fee, higher co-payment, or higher coinsurance amount; or interfering with a patient's ability to obtain a clinician-administered drug from the patient's provider or pharmacy of choice by any means, including but not limited to inducing, steering, or offering financial or other incentives.
Carriers and PBMs shall not impose any penalty, impediment, differentiation, or limitation on any pharmacy that is dispensing medically necessary clinician-administered drugs, regardless of whether the participating provider obtains the drugs from an in-network provider, including but not limited to requiring a pharmacy to dispense the drugs to a patient with the intention that the patient will transport the medication to a health care provider for administration.
These provisions shall not apply if the clinician-administered drug is not otherwise covered by the carrier or PBM.
These provisions are identical to provisions in SB 13 (2025), the introduced SB 751 (2024), HCS/HB 2267 (2024), SB 26 (2023), HCS/HB 198 (2023), SB 1129 (2022), and HB 2305 (2022), and similar to provisions in SB 921 (2022), SB 1129 (2022), and HB 2305 (2022).
REFERENCE PRODUCTS AND BIOSIMILARS (Section 376.415)
A health carrier or PBM providing coverage for a reference product or a biological product that is biosimilar to the reference product shall provide coverage for the reference product and all biological products that have been deemed biosimilar to the reference product. The scope, extent, and amount of the required coverage shall be the same, including but not limited to any payment limitations or cost-sharing obligations.
These provisions are identical to provisions in SB 13 (2025), the introduced SB 751 (2024), HCS/HB 2267 (2024), SB 26 (2023), HCS/HB 198 (2023), SB 1129 (2022), and HB 2305 (2022), and similar to provisions in SB 921 (2022), SB 1129 (2022), and HB 2305 (2022).
340B DRUG PRICING PROGRAM (Section 376.416)
Under this act, no health carrier or pharmacy benefits manager (PBM) shall discriminate against a covered entity or a pharmacy, as such terms are defined in the act, by:
• Reimbursing a covered entity or pharmacy for a quantity of a 340B drug, as defined in the act, in an amount less than the carrier, PBM, or affiliate would pay to any other similarly situated pharmacy for such quantity of the drug on the basis that the entity or pharmacy is a covered entity or a pharmacy, or that the entity or pharmacy dispenses 340B drugs. (Section 376.416.2(1));
• Imposing any terms or conditions on covered entities or pharmacies which differ from the terms or conditions applicable to other similarly situated pharmacies or entities on the basis that the entity or pharmacy is a covered entity or dispenses 340B drugs, including but not limited to certain terms and conditions described in the act. (Section 376.416.2(2));
• Interfering with an individual's choice to receive a 340B drug from a covered entity or pharmacy. (Section 376.416.2(3));
• Discriminating in reimbursement to a covered entity or pharmacy based on the determination or indication a drug is a 340B drug. (Section 376.416.2(4));
• Requiring a covered entity or pharmacy to identify a 340B drug sooner than 45 days after the point of sale of the drug. (Section 376.416.2(5));
• Refusing to contract with a covered entity or pharmacy for reasons other than those that apply equally to entities or pharmacies that are not covered entities or similarly situated pharmacies, or on the basis that the entity or pharmacy is a covered entity as described under federal law, or on the basis that the entity or pharmacy is described as a covered entity under provisions of federal law. (Section 376.416.2(6));
• Denying the covered entity the ability to purchase drugs at 340B program pricing by substituting a rebate discount. (Section 376.416.2(7));
• Refusing to cover drugs purchased under the 340B drug pricing program. (Section 376.416.2(8)); or
• Requiring a covered entity or pharmacy to reverse, resubmit, or clarify a 340B-drug pricing claim after the initial adjudication unless these actions are in the normal course of pharmacy business and not related to the 340B drug pricing, except as required by federal law. (Section 376.416.2(9)).
The Director of the Department of Commerce and Insurance shall impose a civil penalty on any health carrier or PBM violating certain provisions of the act, not to exceed $5,000 per violation per day. (Section 376.416.3).
These provisions are identical to provisions in SB 13 (2025), and similar to provisions in SB 372 (2025), HB 784 (2025), HB 785 (2025), HB 943 (2025), the introduced SB 751 (2024), SCS/SBs 978 & 1035 (2024), SB 1213 (2024), HCS/HB 2267 (2024), HB 1977 (2024), SB 26 (2023), HCS/HB 198 (2023), SB 426 (2023), HB 197 (2023), SB 921 (2022), HCS/HB 1677 (2022), SB 1129 (2022), and HB 2305 (2022).
PRIOR AUTHORIZATION OF HEALTH CARE SERVICES (Sections 376.2100, 376.2102, 376.2104, 376.2106, and 376.2108)
This act enacts provisions relating to prior authorization of health care services.
Beginning January 1, 2027, health care providers shall not be required to obtain prior authorization for a health care service unless the health carrier or utilization review entity determines that in the most recent evaluation period, as defined in the act, less than 90% of the prior authorization requests submitted by that provider for that health care service were approved or would have been approved.
Also beginning January 1, 2027, health care providers shall not be required to obtain prior authorization for any health care services unless the health carrier or utilization review entity has approved or would have approved less than 90% of all prior authorization requests submitted by that provider for health care services.
Health carriers or utilization review entities may elect to have certain hospitals determine which of certain conditions, laid out in the act, the hospital will comply with in order to obtain a prior authorization exemption under the act.
Exemptions from prior authorization under the act shall not apply to: pharmacy services, not to exceed the amount of $100,000; imaging services, not to exceed $100,000; cosmetic procedures that are not medically necessary; or investigative or experimental treatments. Maximum dollar amounts for these exceptions shall be adjusted annually for inflation as described in the act.
The act further specifies certain prior authorization requests that shall not be included in making determinations under the act, specifies identification methods for the providers, includes provisions for the auditing and retraction of determinations under the act, allows for health carriers and utilization review entities to require providers to use an online portal to submit prior authorization requests, requires adverse determinations under the act to be reviewed by a clinical peer of the provider, and requires a grace period for patients who have received prior authorization for a 90-day supply of medication.
Health carriers and utilization review entities shall notify providers within 25 days after a determination is made under the act, shall include in the notification certain information used in making the determination, shall establish an appeals process for the providers, and shall maintain an online prior authorization portal as described in the act.
No health carrier or utilization review entity shall deny or reduce payment to a health care provider for a health care service for which the provider has prior authorization, except as described in the act.
These provisions shall not apply to MO HealthNet services not provided through a managed care organization, or to providers who have not participated in a health benefit plan offered by the health carrier for at least one full evaluation period.
These provisions are identical to HCS/SS#2/SB 79 (2025), HB 618 (2025), and similar to SB 230 (2025), SB 983 (2024), HB 1976 (2024), SB 576 (2023), and HB 1045 (2023).
JIM ERTLE