{"id":30320,"date":"2026-02-13T00:00:00","date_gmt":"2026-02-13T05:00:00","guid":{"rendered":"https:\/\/www.resourcepro.com\/bulletin\/pbms-in-louisiana-must-bring-pharmacy-reimbursement-formulas-into-fair-and-reasonable-compliance-by-march-1-2026\/"},"modified":"2026-02-13T00:00:00","modified_gmt":"2026-02-13T05:00:00","slug":"pbms-in-louisiana-must-bring-pharmacy-reimbursement-formulas-into-fair-and-reasonable-compliance-by-march-1-2026","status":"publish","type":"bulletin","link":"https:\/\/www.resourcepro.com\/bulletin\/pbms-in-louisiana-must-bring-pharmacy-reimbursement-formulas-into-fair-and-reasonable-compliance-by-march-1-2026\/","title":{"rendered":"PBMs in Louisiana Must Bring Pharmacy Reimbursement Formulas Into \u201cFair and Reasonable\u201d Compliance by March 1, 2026"},"content":{"rendered":"\n<p><strong>LA<\/strong>| <a href=\"https:\/\/ldi.la.gov\/docs\/default-source\/documents\/legaldocs\/directives\/dir257-cur-pharmacybenefitmanag\" target=\"_blank\" rel=\"noreferrer noopener\">Directive 257<\/a> explains how the <strong>Louisiana Department of Insurance<\/strong> is <span style=\"text-decoration: underline;\">implementing Act 474 by setting a minimum \u201cfair and reasonable\u201d reimbursement standard for local pharmacies: pharmacy benefit managers (PBMs) serving Louisiana health plans (fully insured, self-funded, and governmental, but not Medicare, Medicaid, or OGB plans) must use a reimbursement formula based on NADAC plus a combined 9.00 markup and professional dispensing fee (PDF) for a 30\u2011day supply<\/span>, which LDI identifies as the market\u2011based minimum that satisfies the statutory requirement that payments to local pharmacies include a non\u2011nominal, fair, and reasonable PDF; this determination is grounded in legislative history (Acts 768 and 474 and the rejection of a Medicaid\u2011level PDF floor), historical NADAC implementation (including the Office of Group Benefits\u2019 9.00 PDF), and a 2026 data call showing prevailing commercial formulas, while clarifying that LDI has no authority to impose a Medicaid\u2011equivalent PDF floor and <strong><em>giving PBMs until March 1, 2026 to bring their contracts and systems into compliance.<\/em><\/strong><\/p>\n\n\n\n<p><strong><span style=\"text-decoration: underline;\">Key Points:<\/span><\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>The directive rejects using Medicaid\u2019s 11.81 PDF as a mandatory floor<\/strong>, finding no statutory authority for such a requirement and emphasizing that LDI\u2019s role is to enforce fair and reasonable compensation based on commercial market practice, not to \u201chide\u201d a higher PDF floor in general oversight language.<\/li>\n\n\n\n<li><strong>PBMs subject to Act 474 must reimburse local pharmacies<\/strong> using a NADAC\u2011based formula that includes a real, non\u2011de minimis professional dispensing fee, with benefits like Medicare, Medicaid, and OGB expressly excluded.<\/li>\n\n\n\n<li><strong>LDI concludes that any PBM formula paying less than NADAC<\/strong> plus a combined 9.00 markup and PDF per 30\u2011day supply is per se not fair and reasonable under Louisiana law and must be corrected by March 1, 2026.<\/li>\n<\/ul>\n\n\n\n<p><strong><em><a href=\"https:\/\/ldi.la.gov\/docs\/default-source\/documents\/legaldocs\/directives\/dir257-cur-pharmacybenefitmanag\" target=\"_blank\" rel=\"noreferrer noopener\">Click here to see LA DOI Directive 257<\/a><\/em><\/strong><\/p>\n","protected":false},"featured_media":21543,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"footnotes":""},"department":[252],"state":[308],"class_list":["post-30320","bulletin","type-bulletin","status-publish","format-standard","has-post-thumbnail","hentry","department-department-of-insurance","state-louisiana"],"acf":[],"publishpress_future_workflow_manual_trigger":{"enabledWorkflows":[]},"_links":{"self":[{"href":"https:\/\/www.resourcepro.com\/wp-json\/wp\/v2\/bulletin\/30320","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.resourcepro.com\/wp-json\/wp\/v2\/bulletin"}],"about":[{"href":"https:\/\/www.resourcepro.com\/wp-json\/wp\/v2\/types\/bulletin"}],"version-history":[{"count":0,"href":"https:\/\/www.resourcepro.com\/wp-json\/wp\/v2\/bulletin\/30320\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.resourcepro.com\/wp-json\/wp\/v2\/media\/21543"}],"wp:attachment":[{"href":"https:\/\/www.resourcepro.com\/wp-json\/wp\/v2\/media?parent=30320"}],"wp:term":[{"taxonomy":"department","embeddable":true,"href":"https:\/\/www.resourcepro.com\/wp-json\/wp\/v2\/department?post=30320"},{"taxonomy":"state","embeddable":true,"href":"https:\/\/www.resourcepro.com\/wp-json\/wp\/v2\/state?post=30320"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}