蘑菇视频

Independent and small-chain pharmacies across Idaho received another major win in the state's ongoing PBM reform efforts after the Idaho Department of Insurance finalized a settlement with Prime Therapeutics LLC on April 15, 2026. Under the settlement, Prime Therapeutics agreed to implement mechanisms ensuring that all independent and small-chain pharmacies in Idaho receive a dispensing fee of at least $11.26 per commercial prescription claim from now on. 

The agreement followed allegations by the Idaho Department of Insurance that Prime Therapeutics failed to provide pharmacies with dispensing fees that reasonably covered the cost of dispensing medications as required under Idaho's 2025 PBM reform law. According to the Department, dispensing fees paid by Prime Therapeutics on the claims reviewed ranged from $0.00 to $2.00 per prescription. The Department also cited findings from Idaho's 2025 pharmacy cost of dispensing survey, which determined that the weighted median dispensing cost for Idaho community retail pharmacies was $11.26 per prescription. As part of the settlement, Prime Therapeutics stipulated that certain dispensing fees paid under its network arrangements were not compliant with Idaho Code 41-349(11)(i), including issues involving claims under the ESI network and contractual arrangements with Cambia Health Solutions. Prime Therapeutics agreed to pay a $48,000 administrative penalty as part of the final order approved by the Idaho Department of Insurance

The settlement marks another significant milestone in Idaho's PBM reform implementation and highlights the growing impact of pharmacy complaints, regulatory oversight, and collaborative advocacy efforts led by independent pharmacies, legislators, and partners, including 蘑菇视频 L.S. Skaggs College of Pharmacy and CAPPRE. 

Prime Therapeutics Final Stipulation 04152026.pdf

Idaho pharmacies scored a major victory in the state's ongoing PBM reform efforts after the Idaho Department of Insurance finalized a settlement with CarelonRx, Blue Cross of Idaho's pharmacy benefit manager, on February 26, 2026.

Under the settlement, CarelonRx agreed to pay a dispensing fee of $11.51 per prescription for all prescriptions dispensed in Idaho going forward, marking one of the most significant enforcement actions to date under Idaho's 2025 PBM reform law.

The settlement stemmed from a complaint filed by the Idaho Department of Insurance, alleging that CarelonRx failed to provide pharmacists with a reasonable dispensing fee as required under Idaho law. Investigators found multiple instances where Idaho pharmacies received dispensing fees ranging from $0.00 to $1.50 per prescription. This was far below the state's surveyed cost to dispense medications. As part of the agreement, CarelonRx admitted to 17 violations of Idaho Code 41-349(11)(i), agreed to pay an $85,000 administrative penalty, and must reimburse affected pharmacies at the new dispensing fee amount for the prescriptions identified in the complaint. 

The settlement represents an important early success for Idaho's PBM reform efforts and demonstrates how pharmacy complaints and regulatory oversight are already helping improve reimbursement accountability for independent pharmacies statewide. 

Carelonrx Final Stipulation 02262026.pdf

Beginning January 1, 2025, Idaho's new Pharmacy Benefit Manager (PBM) reform law increases transparency and creates stronger protections for patients and pharmacies across the state. The law required PBMs and insurance companies acting as PBMs to follow new rules designed to ensure fairer prescription drug pricing and reimbursement practices.

Under the new law:

• PBMs must pass 100% of manufacturer rebates and discounts back to health plans
• PBMs must use "pass-through pricing," preventing them from charging insurers more than they pay pharmacies and keeping the difference
• Pharmacies must receive dispensing fees that reasonably cover the cost of filling prescriptions
• Pharmacies now have access to a formal appeals process when reimbursement payments are inadequate
• PBMs cannot retaliate against pharmacies or pharmacists who report concerns to regulators or law enforcement

The law also requires PBMs to regularly report reimbursement and pricing information to the Idaho Department of Insurance (DOI) to improve oversight and accountability. 

Patients, pharmacies, and healthcare providers who believe a PBM or insurer may not be complying with Idaho law can file a complaint with the Idaho Department of Insurance. Complaints can be submitted online through the Department's or by contacting the Department directly. 

Idaho Department of Insurance

ATTN: Pharmacy Benefit Market Examiner

700 W State St, 3rd Floor

Boise, ID 83720-0043

Fax: (208) 334-4398

Email: pbmcomplaints@doi.idaho.gov