West Virginia § 9-5-34 - 9-5-34. Medicaid pharmacy benefit management; prohibited contracting; pharmacy cost containment tool.

§ 9-5-34. 9-5-34. Medicaid pharmacy benefit management; prohibited contracting; pharmacy cost containment tool.

(a) For purposes of this section, "pharmacy benefit manager" and "affiliate" have the meanings ascribed to those terms in §33-51-3 of this code.

(b) To the extent that Medicaid has a pharmacy benefit manager managing its pharmacy contract, that pharmacy benefit manager may not reimburse a pharmacy or pharmacist for a prescription drug or pharmacy service in an amount less than the amount the pharmacy benefit manager reimburses itself or an affiliate for the same prescription drug or pharmacy service.

(c) By July 1, 2026, the Medicaid program shall establish a one-year pilot program to implement a pharmacy cost containment vendor. This pilot program shall focus on actively engaging prescribing providers by presenting information regarding cost and effectiveness, including but not limited to, data on lowest net cost pharmaceutical options and clinically appropriate polypharmacy reduction strategies. This pilot program will not require Medicaid to alter or violate any terms of any existing contractual agreements.

(1) Participation in the pilot program does not mandate changes in clinical practice, as prescribing providers engaged by the vendor retain clinical discretion and are not required to modify prescribing patterns based on information presented. The vendor managing this service shall be separate and distinct from any pharmacy benefit management contract that any state agency may have in the management of the pharmacy benefit.

(2) The state expenditure on the pilot program may not increase relative to the protected savings generated from the pilot program. Any cost containment vendor utilized by Medicaid under this pilot program must agree to the terms that reflect contractual savings to fee guarantee.

(3) Prescribing providers engaged by the vendor are not required to modify their prescribing based on the information presented pursuant to this subsection.

(4) If the pilot program determines a net savings, Medicaid may enter into a contractual arrangement with the vendor prior to the conclusion of the pilot program to ensure long term savings are achieved.