Weekly Legislative Update: Week 3

January 22, 2026

No. 3 

PRIOR AUTHORIZATION BILL FILED

If there could be a theme for the week from our healthcare lens, it would be: Insurance goes under the knife! And we are here for the slicing and dicing! To kick off the short week, our prior authorization reform bill, HB 3010 was filed. This bill is similar to our past efforts, but we’re including some fine-tuning from the Department of Insurance this year. This bill is designed to reduce administrative drag and protect patients from delays to their care. It tightens decision‑making timelines, requires clear clinical rationales for denials, and strengthens continuity‑of‑care protections so patients aren’t forced to restart the authorization process when they change plans. It also extends the validity of prior authorizations for up to six months on most services and twelve months for chronic‑condition treatments. Physicians should not be repeatedly forced to re-justify stable care plans.

A key provision returning in this year’s bill is the gold card‑style exemption beginning in 2027. This simply means if a physician’s prior authorization requests for a service are approved at least 90% of the time, the insurer can no longer require prior authorization for that service. The bill also mandates electronic submission through a standardized and uniform interface, requires carriers to publicly report their prior authorization statistics, and automatically deems services authorized when insurers miss statutory deadlines.

We are improving access with HB 3010. It directly targets the administrative barriers that pull physicians away from patient care and delay medically necessary treatment. By reducing unnecessary authorizations, increasing transparency, and protecting continuity of care, the bill helps ensure patients receive timely, clinically appropriate services without bureaucratic roadblocks. 

MULTIFACETED PBM REFORM

Missouri’s push to rein in pharmacy benefit managers (PBMs) accelerated this week on multiple fronts. These efforts reflect a growing recognition among lawmakers and regulators that PBM business practices are driving higher drug costs, destabilizing pharmacy access, and undermining continuity of care. Between a major lawsuit filed by the Attorney General and two active Senate bills, there appears to be a coordinated run at the obscure pricing and contracting mechanisms that have long distorted the prescription drug market for patients and physicians alike.

Last week, the Attorney General filed a lawsuit against the three dominant PBMs and leading insulin manufacturers, alleging a coordinated “insulin pricing scheme” that inflated list prices from roughly $20 to several hundred dollars despite production costs of under $2. The suit alleges manufacturers drove list prices higher to bankroll big, obscure payments to PBMs in exchange for formulary placement. It also asserts PBMs allegedly kept those payments while shutting out cheaper options. For Missouri patients, especially those with diabetes, the result has been years of unaffordable medication and restricted access.

This Wednesday, the Senate Committee on Families, Seniors, and Health heard SB 984 and SB 968. Senate Bill 984advances a broad package of transparency and fair dealing PBM reforms. The bill expands the Department of Commerce and Insurance’s authority to audit PBMs, requires PBMs to share pharmacy claims data with plan sponsors, and prohibits charging patients more than the lowest available price at the counter. It also strengthens pharmacy audit protections and creates the Critical Access Care Pharmacy Program to support rural and underserved communities.

Complementing these efforts, SB 968 targets PBM reimbursement practices and anti‑competitive steering. The bill prohibits PBMs from pushing patients toward preferred pharmacies or penalizing them for choosing otherwise. Furthermore, it blocks PBMs from imposing accreditation requirements beyond what Missouri law demands. It also establishes reimbursement floors tied to National Average Drug Acquisition Cost or maximum allowable cost and requires parity with payments made to PBM‑affiliated pharmacies. Additional protections ensure pharmacies can appeal underpayments without retaliation and receive a dispensing fee aligned with MO HealthNet standards.

We are doing a happy dance over all this activity! Missouri is poised to finally confront the profits-over-patients practices of PBMs that have inflated drug costs, disrupted pharmacy access, and complicated care for patients with chronic conditions. The AG’s lawsuit and the Senate’s multifaceted reform bills share a common goal of restoring transparency, fairness, and patient‑centered decision‑making in the prescription drug system. As these efforts move forward, you can help us stand up for your patients. Physician voices remain essential in highlighting how PBM policies affect real‑world care delivery and patient outcomes.

DEATH BY A THOUSAND CUTS

Thursday’s House Health and Mental Health Committee tackled a variety of insurance bills. The committee heard four separate bills (HB 1680, HB 1966, HB 2296, and HB 2642), each addressing insurance coverage of non‑opioid alternatives for acute pain. These proposals would prohibit insurers from denying coverage of non‑opioid medications in favor of opioids, requiring patients to “fail first” on opioids, or charging higher cost‑sharing for safer alternatives. We’re keeping an eye on these to ensure physicians retain the right to prescribe medications they believe are best for their patients.

This week’s hearings reflect a growing legislative recognition that insurance protocols and programs have become a major determinant of clinical care. Unfortunately, they all too often influence prescribing decisions, reimbursement predictability, care coordination, and the ability of patients to access timely, appropriate treatments. These bills and others heard this week are just a tiny sampling of bills that have been filed to reform insurance tactics that get in the way of physicians’ ability to practice medicine and also put Missouri patients’ health at risk. We are happy to be loud and proud on behalf of your profession and your patients! We will keep you informed on all the good and bad insurance bills as session progresses. Cross your fingers for a year of reformation.