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H 4790

Pharmacy Benefits Managers - Maximum Allowable Cost Lists

2025-2026 Regular Session Introduced by Brandon Cox and 12 co-sponsors

The bill requires PBMs to publish unobstructed, regularly updated MAC lists (every 7 days) with internal and external appeal options, benefiting patients and all pharmacies.

Member(s) request name added as sponsor: Crawford, Hardee
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Bill Summary · H 4790

Summary: Bill H 4790 (2025-2026) – South Carolina Pharmacy Benefits Managers (PBMs) Maximum Allowable Cost Lists

Purpose and intent

  • The bill amends the South Carolina Code to require Pharmacy Benefits Managers (PBMs) to provide open and unobstructed access to their Maximum Allowable Cost (MAC) Lists.
  • The goal is to increase transparency and predictability of drug pricing for patients, consumers, network pharmacies, and pharmacies subject to MAC pricing.

Key provisions and changes

  1. Unobstructed access to MAC Lists

    • PBMs must provide process for network pharmacies to readily access MAC specific to each provider.
    • Patients, consumers, and network pharmacies must have unobstructed access to MAC Lists.

  2. Frequent updates to MAC Lists

    • MAC Lists must be updated at least every seven calendar days.

  3. Access to updates for each pharmacy

    • Each pharmacy subject to MAC pricing must have access to updates to the MAC List.
    • PBMs must provide unobstructed access to these updates.

  4. Dispensing fees excluded from MAC calculations

    • The calculation of MAC must not include dispensing fees.

  5. Internal appeal process for under-reimbursed drugs

    • PBMs must establish a reasonable internal appeal procedure if reimbursement for a drug under MAC pricing is less than the net amount the network provider paid to suppliers.
    • Required elements:
      • A dedicated telephone number and email/website for submitting internal appeals.
      • Ability to submit internal appeals directly to the PBM (and/or through a pharmacy service administrator if applicable under contract).

  6. External review option

    • PBMs must participate in a reasonable external review procedure.
    • Contracted pharmacies can request an external review of a PBM’s denial of an internal appeal by an independent review organization, in line with procedures promulgated by the director (as described in subsection F, not provided in the excerpt).

  7. Access for unaffiliated retail pharmacies

    • Unaffiliated retail pharmacies may participate in programs that reconcile payments with actual cost on the same basis as affiliated retail pharmacy benefits manager participants.

Affected parties

  • Pharmacy Benefits Managers (PBMs): Primary regulatory requirements in MAC access, update frequency, appeals, and external review.
  • Network pharmacies and pharmacies subject to MAC pricing: Must have unobstructed access to MAC lists and updates; eligible to participate in reconciliation programs; can pursue internal and external appeals.
  • Patients and consumers: Guaranteed access to MAC information; increased transparency in pricing.
  • Unaffiliated retail pharmacies: Eligible to participate in MAC-related reconciliation programs on the same basis as affiliated pharmacies.

Procedural and timeline aspects

  • The bill specifies a 7-day minimum update cadence for MAC Lists.
  • It creates a framework for:
    • Internal appeals (with contact channels and direct PBM submission options).
    • External reviews (via independent review organizations per director's promulgation).
  • Effective date: The act becomes law upon the Governor’s approval.

Practical impact considerations

  • Increased transparency may reduce confusion over drug pricing and reimbursement disparities.
  • Regular 7-day MAC updates could lead to more timely reflection of supplier costs.
  • Providing robust internal and external appeal processes may improve disputes over reimbursements for MAC-priced drugs.
  • Exclusion of dispensing fees from MAC calculations prevents fee stacking from distorting MAC-based pricing.
  • Having unaffiliated pharmacies participate in cost reconciliation programs could broaden access to MAC-based pricing benefits.

Note: The summary reflects the bill text available and action history up to the current date. If enacted, further implementing regulations and director-adopted procedures will shape operational details.

Compiled from official sources — confirm details with the bill’s official record.

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