The legislature finds that growth in managed health care systems has shifted substantial authority over health care decisions from providers and patients to health carriers and health care benefit managers. Health care benefit managers acting as intermediaries between carriers, health care providers, and patients exercise broad discretion to affect health care services recommended and delivered by providers and the health care choices of patients. Regularly, these health care benefit managers are making health care decisions on behalf of carriers. However, unlike carriers, health care benefit managers are not currently regulated.
Therefore, the legislature finds that it is in the best interest of the public to create a separate chapter in this title for health care benefit managers.
The legislature intends to protect and promote the health, safety, and welfare of Washington residents by establishing standards for regulatory oversight of health care benefit managers.
[ 2020 c 240 § 1; ]
The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.
"Affiliate" or "affiliated employer" means a person who directly or indirectly through one or more intermediaries, controls or is controlled by, or is under common control with, another specified person.
"Certification" has the same meaning as in RCW 48.43.005.
"Employee benefits programs" means programs under both the public employees' benefits board established in RCW 41.05.055 and the school employees' benefits board established in RCW 41.05.740.
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"Health care benefit manager" means a person or entity providing services to, or acting on behalf of, a health carrier or employee benefits programs, that directly or indirectly impacts the determination or utilization of benefits for, or patient access to, health care services, drugs, and supplies including, but not limited to:
Prior authorization or preauthorization of benefits or care;
Certification of benefits or care;
Medical necessity determinations;
Utilization review;
Benefit determinations;
Claims processing and repricing for services and procedures;
Outcome management;
Provider credentialing and recredentialing;
ix. Payment or authorization of payment to providers and facilities for services or procedures;
Provider network management; or
Disease management.
"Health care benefit manager" includes, but is not limited to, health care benefit managers that specialize in specific types of health care benefit management such as pharmacy benefit managers, radiology benefit managers, laboratory benefit managers, and mental health benefit managers.
"Health care benefit manager" does not include:
Health care service contractors as defined in RCW 48.44.010;
Health maintenance organizations as defined in RCW 48.46.020;
Issuers as defined in RCW 48.01.053;
The public employees' benefits board established in RCW 41.05.055;
The school employees' benefits board established in RCW 41.05.740;
Discount plans as defined in RCW 48.155.010;
Direct patient-provider primary care practices as defined in RCW 48.150.010;
An employer administering its employee benefit plan or the employee benefit plan of an affiliated employer under common management and control;
ix. A union administering a benefit plan on behalf of its members;
A creditor acting on behalf of its debtors with respect to insurance, covering a debt between the creditor and its debtors;
A behavioral health administrative services organization or other county-managed entity that has been approved by the state health care authority to perform delegated functions on behalf of a carrier;
A hospital licensed under chapter 70.41 RCW or ambulatory surgical facility licensed under chapter 70.230 RCW;
The Robert Bree collaborative under chapter 70.250 RCW;
The health technology clinical committee established under RCW 70.14.090; or
The prescription drug purchasing consortium established under RCW 70.14.060.
"Health care provider" or "provider" has the same meaning as in RCW 48.43.005.
"Health care service" has the same meaning as in RCW 48.43.005.
"Health carrier" or "carrier" has the same meaning as in RCW 48.43.005.
"Laboratory benefit manager" means a person or entity providing service to, or acting on behalf of, a health carrier, employee benefits programs, or another entity under contract with a carrier, that directly or indirectly impacts the determination or utilization of benefits for, or patient access to, health care services, drugs, and supplies relating to the use of clinical laboratory services and includes any requirement for a health care provider to submit a notification of an order for such services.
"Mental health benefit manager" means a person or entity providing service to, or acting on behalf of, a health carrier, employee benefits programs, or another entity under contract with a carrier, that directly or indirectly impacts the determination of utilization of benefits for, or patient access to, health care services, drugs, and supplies relating to the use of mental health services and includes any requirement for a health care provider to submit a notification of an order for such services.
"Network" means the group of participating providers, pharmacies, and suppliers providing health care services, drugs, or supplies to beneficiaries of a particular carrier or plan.
"Person" includes, as applicable, natural persons, licensed health care providers, carriers, corporations, companies, trusts, unincorporated associations, and partnerships.
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"Pharmacy benefit manager" means a person that contracts with pharmacies on behalf of an insurer, a third-party payor, or the prescription drug purchasing consortium established under RCW 70.14.060 to:
Process claims for prescription drugs or medical supplies or provide retail network management for pharmacies or pharmacists;
Pay pharmacies or pharmacists for prescription drugs or medical supplies;
Negotiate rebates with manufacturers for drugs paid for or procured as described in this subsection;
Manage pharmacy networks; or
Make credentialing determinations.
"Pharmacy benefit manager" does not include a health care service contractor as defined in RCW 48.44.010.
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"Radiology benefit manager" means any person or entity providing service to, or acting on behalf of, a health carrier, employee benefits programs, or another entity under contract with a carrier, that directly or indirectly impacts the determination or utilization of benefits for, or patient access to, the services of a licensed radiologist or to advanced diagnostic imaging services including, but not limited to:
Processing claims for services and procedures performed by a licensed radiologist or advanced diagnostic imaging service provider; or
Providing payment or payment authorization to radiology clinics, radiologists, or advanced diagnostic imaging service providers for services or procedures.
"Radiology benefit manager" does not include a health care service contractor as defined in RCW 48.44.010, a health maintenance organization as defined in RCW 48.46.020, or an issuer as defined in RCW 48.01.053.
"Utilization review" has the same meaning as in RCW 48.43.005.
"Critical access pharmacy" means a pharmacy in Washington that is further than a 15-mile radius from any other pharmacy, is the only pharmacy on an island, or provides critical services to vulnerable populations. If one critical access pharmacy's 15-mile radius intersects with that of another critical access pharmacy, both shall be considered a critical access pharmacy if either critical access pharmacy's closure could result in impaired access for rural areas or for vulnerable populations. The health care authority's chief pharmacy officer may also further identify pharmacies as critical access based on their unique ability to care for a population.
To conduct business in this state, a health care benefit manager must register with the commissioner and annually renew the registration.
To apply for registration under this section, a health care benefit manager must:
Submit an application on forms and in a manner prescribed by the commissioner and verified by the applicant by affidavit or declaration under chapter 5.50 RCW. Applications must contain at least the following information:
The identity of the health care benefit manager and of persons with any ownership or controlling interest in the applicant including relevant business licenses and tax identification numbers, and the identity of any entity that the health care benefit manager has a controlling interest in;
The business name, address, phone number, and contact person for the health care benefit manager;
Any areas of specialty such as pharmacy benefit management, radiology benefit management, laboratory benefit management, mental health benefit management, or other specialty; and
Any other information as the commissioner may reasonably require.
Pay an initial registration fee and annual renewal registration fee as established in rule by the commissioner. The fees for each registration must be set by the commissioner in an amount that ensures the registration, renewal, and oversight activities are self-supporting. If one health care benefit manager has a contract with more than one carrier, the health care benefit manager must complete only one application providing the details necessary for each contract.
All receipts from fees collected by the commissioner under this section must be deposited into the insurance commissioner's regulatory account created in RCW 48.02.190.
Before approving an application for or renewal of a registration, the commissioner must find that the health care benefit manager:
Has not committed any act that would result in denial, suspension, or revocation of a registration;
Has paid the required fees; and
Has the capacity to comply with, and has designated a person responsible for, compliance with state and federal laws.
Any material change in the information provided to obtain or renew a registration must be filed with the commissioner within thirty days of the change.
Every registered health care benefit manager must retain a record of all transactions completed for a period of not less than seven years from the date of their creation. All such records as to any particular transaction must be kept available and open to inspection by the commissioner during the seven years after the date of completion of such transaction.
[ 2020 c 240 § 3; ]
A health care benefit manager may not provide health care benefit management services to a health carrier or employee benefits programs without a written agreement describing the rights and responsibilities of the parties conforming to the provisions of this chapter and any rules adopted by the commissioner to implement or enforce this chapter including rules governing contract content.
A health care benefit manager must file with the commissioner in the form and manner prescribed by the commissioner, every benefit management contract and contract amendment between the health care benefit manager and a provider, pharmacy, pharmacy services administration organization, or other health care benefit manager, entered into directly or indirectly in support of a contract with a carrier or employee benefits programs, within thirty days following the effective date of the contract or contract amendment.
Contracts filed under this section are confidential and not subject to public inspection under RCW 48.02.120(2), or public disclosure under chapter 42.56 RCW, if filed in accordance with the procedures for submitting confidential filings through the system for electronic rate and form filings and the general filing instructions as set forth by the commissioner. In the event the referenced filing fails to comply with the filing instructions setting forth the process to withhold the contract from public inspection, and the health care benefit manager indicates that the contract is to be withheld from public inspection, the commissioner must reject the filing and notify the health care benefit manager through the system for electronic rate and form filings to amend its filing to comply with the confidentiality filing instructions.
[ 2020 c 240 § 4; ]
Upon notifying a carrier or health care benefit manager of an inquiry or complaint filed with the commissioner pertaining to the conduct of a health care benefit manager identified in the inquiry or complaint, the commissioner must provide notice of the inquiry or complaint concurrently to the health care benefit manager and any carrier to which the inquiry or complaint pertains.
Upon receipt of an inquiry from the commissioner, a health care benefit manager must provide to the commissioner within fifteen business days, in the form and manner required by the commissioner, a complete response to that inquiry including, but not limited to, providing a statement or testimony, producing its accounts, records, and files, responding to complaints, or responding to surveys and general requests. Failure to make a complete or timely response constitutes a violation of this chapter.
Subject to chapter 48.04 RCW, if the commissioner finds that a health care benefit manager or any person responsible for the conduct of the health care benefit manager's affairs has:
Violated any insurance law, or violated any rule, subpoena, or order of the commissioner or of another state's insurance commissioner;
Failed to renew the health care benefit manager's registration;
Failed to pay the registration or renewal fees;
Provided incorrect, misleading, incomplete, or materially untrue information to the commissioner, to a carrier, or to a beneficiary;
Used fraudulent, coercive, or dishonest practices, or demonstrated incompetence, or financial irresponsibility in this state or elsewhere; or
Had a health care benefit manager registration, or its equivalent, denied, suspended, or revoked in any other state, province, district, or territory;
the commissioner may take any combination of the following actions against a health care benefit manager or any person responsible for the conduct of the health care benefit manager's affairs, other than an employee benefits program:
i. Place on probation, suspend, revoke, or refuse to issue or renew the health care benefit manager's registration;
ii. Issue a cease and desist order against the health care benefit manager and contracting carrier;
iii. Fine the health care benefit manager up to five thousand dollars per violation, and the contracting carrier is subject to a fine for acts conducted under the contract;
iv. Issue an order requiring corrective action against the health care benefit manager, the contracting carrier acting with the health care benefit manager, or both the health care benefit manager and the contracting carrier acting with the health care benefit manager; and
v. Temporarily suspend the health care benefit manager's registration by an order served by mail or by personal service upon the health care benefit manager not less than three days prior to the suspension effective date. The order must contain a notice of revocation and include a finding that the public safety or welfare requires emergency action. A temporary suspension under this subsection (3)(f)(v) continues until proceedings for revocation are concluded.
A stay of action is not available for actions the commissioner takes by cease and desist order, by order on hearing, or by temporary suspension.
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Health carriers and employee benefits programs are responsible for the compliance of any person or organization acting directly or indirectly on behalf of or at the direction of the carrier or program, or acting pursuant to carrier or program standards or requirements concerning the coverage of, payment for, or provision of health care benefits, services, drugs, and supplies.
A carrier or program contracting with a health care benefit manager is responsible for the health care benefit manager's violations of this chapter, including a health care benefit manager's failure to produce records requested or required by the commissioner.
No carrier or program may offer as a defense to a violation of any provision of this chapter that the violation arose from the act or omission of a health care benefit manager, or other person acting on behalf of or at the direction of the carrier or program, rather than from the direct act or omission of the carrier or program.
[ 2020 c 240 § 5; ]
The definitions in this section apply throughout this section and RCW 48.200.220 through 48.200.290 unless the context clearly requires otherwise.
"Audit" means an on-site or remote review of the records of a pharmacy by or on behalf of an entity.
"Claim" means a request from a pharmacy or pharmacist to be reimbursed for the cost of filling or refilling a prescription for a drug or for providing a medical supply or service.
"Clerical error" means a minor error:
In the keeping, recording, or transcribing of records or documents or in the handling of electronic or hard copies of correspondence;
That does not result in financial harm to an entity; and
That does not involve dispensing an incorrect dose, amount, or type of medication, or dispensing a prescription drug to the wrong person.
"Entity" includes:
A pharmacy benefit manager;
An insurer;
A third-party payor;
A state agency; or
A person that represents or is employed by one of the entities described in this subsection.
"Fraud" means knowingly and willfully executing or attempting to execute a scheme, in connection with the delivery of or payment for health care benefits, items, or services, that uses false or misleading pretenses, representations, or promises to obtain any money or property owned by or under the custody or control of any person.
"Pharmacist" has the same meaning as in RCW 18.64.011.
"Pharmacy" has the same meaning as in RCW 18.64.011.
"Third-party payor" means a person licensed under RCW 48.39.005.
[ 2020 c 240 § 10; 2014 c 213 § 3; ]
An entity that audits claims or an independent third party that contracts with an entity to audit claims:
Must establish, in writing, a procedure for a pharmacy to appeal the entity's findings with respect to a claim and must provide a pharmacy with a notice regarding the procedure, in writing or electronically, prior to conducting an audit of the pharmacy's claims;
May not conduct an audit of a claim more than twenty-four months after the date the claim was adjudicated by the entity;
Must give at least fifteen days' advance written notice of an on-site audit to the pharmacy or corporate headquarters of the pharmacy;
May not conduct an on-site audit during the first five days of any month without the pharmacy's consent;
Must conduct the audit in consultation with a pharmacist who is licensed by this or another state if the audit involves clinical or professional judgment;
May not conduct an on-site audit of more than two hundred fifty unique prescriptions of a pharmacy in any twelve-month period except in cases of alleged fraud;
May not conduct more than one on-site audit of a pharmacy in any twelve-month period;
Must audit each pharmacy under the same standards and parameters that the entity uses to audit other similarly situated pharmacies;
Must pay any outstanding claims of a pharmacy no more than forty-five days after the earlier of the date all appeals are concluded or the date a final report is issued under RCW 48.200.260(3);
May not include dispensing fees or interest in the amount of any overpayment assessed on a claim unless the overpaid claim was for a prescription that was not filled correctly;
May not recoup costs associated with:
Clerical errors; or
Other errors that do not result in financial harm to the entity or a consumer; and
May not charge a pharmacy for a denied or disputed claim until the audit and the appeals procedure established under subsection (1) of this section are final.
[ 2020 c 240 § 11; 2014 c 213 § 4; ]
An entity's finding that a claim was incorrectly presented or paid must be based on identified transactions and not based on probability sampling, extrapolation, or other means that project an error using the number of patients served who have a similar diagnosis or the number of similar prescriptions or refills for similar drugs.
[ 2014 c 213 § 5; ]
An entity that contracts with an independent third party to conduct audits may not:
Agree to compensate the independent third party based on a percentage of the amount of overpayments recovered; or
Disclose information obtained during an audit except to the contracting entity, the pharmacy subject to the audit, or the holder of the policy or certificate of insurance that paid the claim.
[ 2014 c 213 § 6; ]
For purposes of RCW 48.200.210 through 48.200.270, an entity, or an independent third party that contracts with an entity to conduct audits, must allow as evidence of validation of a claim:
An electronic or physical copy of a valid prescription if the prescribed drug was, within fourteen days of the dispensing date:
Picked up by the patient or the patient's designee;
Delivered by the pharmacy to the patient; or
Sent by the pharmacy to the patient using the United States postal service or other common carrier;
Point of sale electronic register data showing purchase of the prescribed drug, medical supply, or service by the patient or the patient's designee; or
Electronic records, including electronic beneficiary signature logs, electronically scanned and stored patient records maintained at or accessible to the audited pharmacy's central operations, and any other reasonably clear and accurate electronic documentation that corresponds to a claim.
[ 2020 c 240 § 12; 2014 c 213 § 7; ]
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After conducting an audit, an entity must provide the pharmacy that is the subject of the audit with a preliminary report of the audit. The preliminary report must be received by the pharmacy no later than forty-five days after the date on which the audit was completed and must be sent:
By mail or common carrier with a return receipt requested; or
Electronically with electronic receipt confirmation.
An entity shall provide a pharmacy receiving a preliminary report under this subsection no fewer than forty-five days after receiving the report to contest the report or any findings in the report in accordance with the appeals procedure established under RCW 48.200.220(1) and must allow the submission of additional documentation in support of the claim. The entity shall consider a reasonable request for an extension of time to submit documentation to contest the report or any findings in the report.
If an audit results in the dispute or denial of a claim, the entity conducting the audit shall allow the pharmacy to resubmit the claim using any commercially reasonable method, including facsimile, mail, or email.
An entity must provide a pharmacy that is the subject of an audit with a final report of the audit no later than sixty days after the later of the date the preliminary report was received or the date the pharmacy contested the report using the appeals procedure established under RCW 48.200.220(1). The final report must include a final accounting of all moneys to be recovered by the entity.
Recoupment of disputed funds from a pharmacy by an entity or repayment of funds to an entity by a pharmacy, unless otherwise agreed to by the entity and the pharmacy, shall occur after the audit and the appeals procedure established under RCW 48.200.220(1) are final. If the identified discrepancy for an individual audit exceeds forty thousand dollars, any future payments to the pharmacy may be withheld by the entity until the audit and the appeals procedure established under RCW 48.200.220(1) are final.
[ 2020 c 240 § 13; 2014 c 213 § 8; ]
RCW 48.200.210 through 48.200.270 do not:
Preclude an entity from instituting an action for fraud against a pharmacy;
Apply to an audit of pharmacy records when fraud or other intentional and willful misrepresentation is indicated by physical review, review of claims data or statements, or other investigative methods; or
Apply to a state agency that is conducting audits or a person that has contracted with a state agency to conduct audits of pharmacy records for prescription drugs paid for by the state medical assistance program.
[ 2020 c 240 § 14; 2014 c 213 § 9; ]
The definitions in this subsection apply throughout this section unless the context clearly requires otherwise.
"List" means the list of drugs for which predetermined reimbursement costs have been established, such as a maximum allowable cost or maximum allowable cost list or any other benchmark prices utilized by the pharmacy benefit manager and must include the basis of the methodology and sources utilized to determine multisource generic drug reimbursement amounts.
"Multiple source drug" means a therapeutically equivalent drug that is available from at least two manufacturers.
"Multisource generic drug" means any covered outpatient prescription drug for which there is at least one other drug product that is rated as therapeutically equivalent under the food and drug administration's most recent publication of "Approved Drug Products with Therapeutic Equivalence Evaluations;" is pharmaceutically equivalent or bioequivalent, as determined by the food and drug administration; and is sold or marketed in the state during the period.
"Network pharmacy" means a retail drug outlet licensed as a pharmacy under RCW 18.64.043 that contracts with a pharmacy benefit manager.
"Therapeutically equivalent" has the same meaning as in RCW 69.41.110.
A pharmacy benefit manager:
May not place a drug on a list unless there are at least two therapeutically equivalent multiple source drugs, or at least one generic drug available from only one manufacturer, generally available for purchase by network pharmacies from national or regional wholesalers;
Shall ensure that all drugs on a list are readily available for purchase by pharmacies in this state from national or regional wholesalers that serve pharmacies in Washington;
Shall ensure that all drugs on a list are not obsolete;
Shall make available to each network pharmacy at the beginning of the term of a contract, and upon renewal of a contract, the sources utilized to determine the predetermined reimbursement costs for multisource generic drugs of the pharmacy benefit manager;
Shall make a list available to a network pharmacy upon request in a format that is readily accessible to and usable by the network pharmacy;
Shall update each list maintained by the pharmacy benefit manager every seven business days and make the updated lists, including all changes in the price of drugs, available to network pharmacies in a readily accessible and usable format;
Shall ensure that dispensing fees are not included in the calculation of the predetermined reimbursement costs for multisource generic drugs;
May not cause or knowingly permit the use of any advertisement, promotion, solicitation, representation, proposal, or offer that is untrue, deceptive, or misleading;
May not charge a pharmacy a fee related to the adjudication of a claim, credentialing, participation, certification, accreditation, or enrollment in a network including, but not limited to, a fee for the receipt and processing of a pharmacy claim, for the development or management of claims processing services in a pharmacy benefit manager network, or for participating in a pharmacy benefit manager network;
May not require accreditation standards inconsistent with or more stringent than accreditation standards established by a national accreditation organization;
May not reimburse a pharmacy in the state an amount less than the amount the pharmacy benefit manager reimburses an affiliate for providing the same pharmacy services; and
May not directly or indirectly retroactively deny or reduce a claim or aggregate of claims after the claim or aggregate of claims has been adjudicated, unless:
The original claim was submitted fraudulently; or
The denial or reduction is the result of a pharmacy audit conducted in accordance with RCW 48.200.220.
A pharmacy benefit manager must establish a process by which a network pharmacy may appeal its reimbursement for a drug subject to predetermined reimbursement costs for multisource generic drugs. A network pharmacy may appeal a predetermined reimbursement cost for a multisource generic drug if the reimbursement for the drug is less than the net amount that the network pharmacy paid to the supplier of the drug. An appeal requested under this section must be completed within thirty calendar days of the pharmacy submitting the appeal. If after thirty days the network pharmacy has not received the decision on the appeal from the pharmacy benefit manager, then the appeal is considered denied.
The pharmacy benefit manager shall uphold the appeal of a pharmacy with fewer than fifteen retail outlets, within the state of Washington, under its corporate umbrella if the pharmacy or pharmacist can demonstrate that it is unable to purchase a therapeutically equivalent interchangeable product from a supplier doing business in Washington at the pharmacy benefit manager's list price.
A pharmacy benefit manager must provide as part of the appeals process established under subsection (3) of this section:
A telephone number at which a network pharmacy may contact the pharmacy benefit manager and speak with an individual who is responsible for processing appeals; and
If the appeal is denied, the reason for the denial and the national drug code of a drug that has been purchased by other network pharmacies located in Washington at a price that is equal to or less than the predetermined reimbursement cost for the multisource generic drug. A pharmacy with fifteen or more retail outlets, within the state of Washington, under its corporate umbrella may submit information to the commissioner about an appeal under subsection (3) of this section for purposes of information collection and analysis.
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If an appeal is upheld under this section, the pharmacy benefit manager shall make a reasonable adjustment on a date no later than one day after the date of determination.
If the request for an adjustment has come from a critical access pharmacy, the adjustment approved under (a) of this subsection shall apply only to critical access pharmacies.
Beginning July 1, 2017, if a network pharmacy appeal to the pharmacy benefit manager is denied, or if the network pharmacy is unsatisfied with the outcome of the appeal, the pharmacy or pharmacist may dispute the decision and request review by the commissioner within thirty calendar days of receiving the decision.
All relevant information from the parties may be presented to the commissioner, and the commissioner may enter an order directing the pharmacy benefit manager to make an adjustment to the disputed claim, deny the pharmacy appeal, or take other actions deemed fair and equitable. An appeal requested under this section must be completed within thirty calendar days of the request.
Upon resolution of the dispute, the commissioner shall provide a copy of the decision to both parties within seven calendar days.
The commissioner may authorize the office of administrative hearings, as provided in chapter 34.12 RCW, to conduct appeals under this subsection (6).
A pharmacy benefit manager may not retaliate against a pharmacy for pursuing an appeal under this subsection (6).
This subsection (6) applies only to a pharmacy with fewer than fifteen retail outlets, within the state of Washington, under its corporate umbrella.
This section does not apply to the state medical assistance program.
The commissioner shall have enforcement authority over this chapter and shall have authority to render a binding decision in any dispute between a pharmacy benefit manager, or third-party administrator of prescription drug benefits, and a pharmacy arising out of an appeal under RCW 48.200.280(6) regarding drug pricing and reimbursement.
Any person, corporation, third-party administrator of prescription drug benefits, pharmacy benefit manager, or business entity which violates any provision of this chapter shall be subject to a civil penalty in the amount of one thousand dollars for each act in violation of this chapter or, if the violation was knowing and willful, a civil penalty of five thousand dollars for each violation of this chapter.
[ 2020 c 240 § 16; 2016 c 210 § 2; ]
The insurance commissioner may adopt any rules necessary to implement this act.
[ 2020 c 240 § 20; ]
Sections 1 through 19 of this act take effect January 1, 2022.
[ 2020 c 240 § 23; ]
**
A pharmacy benefit manager that administers a prescription drug benefit may not:
Require a covered person to use a mail order pharmacy;
Impose different days allowance to fill for using one participating pharmacy over another participating pharmacy;
Require a covered person to obtain prescriptions from a mail order pharmacy unless the prescription drug is a specialty or limited distribution prescription drug;
Reimburse a covered person's chosen participating pharmacy an amount less than the amount the pharmacy benefit manager reimburses participating affiliated pharmacies; or
Reimburse a nonparticipating pharmacy more than a participating pharmacy.
A pharmacy benefit manager shall:
Provide fair and reasonable reimbursement to the covered person's participating pharmacy of choice;
Include a provision in contracts with participating pharmacies and pharmacy services administrative organizations that authorizes the pharmacy to decline to fill a prescription if the pharmacy benefit manager refuses to reimburse the pharmacy at a rate that is at least equal to the pharmacy's acquisition cost of the drug;
Maintain an adequate and accessible pharmacy network for the provision of prescription drugs for a health benefit plan. The pharmacy network must provide for convenient access for covered persons to pharmacies and critical access pharmacies; and
Permit the covered person to receive delivery or mail order of a medication through any participating pharmacy.
A pharmacy services administration organization must include a provision in contracts with participating pharmacies that authorizes the pharmacy to decline to fill a prescription if the pharmacy services administration organization refuses to reimburse the pharmacy at a rate that is at least equal to the pharmacy's acquisition cost of the drug.
If a covered person is using a mail order pharmacy, the pharmacy benefit manager must:
Allow for dispensing at local participating pharmacies under the following circumstances to ensure patient access to prescription drugs:
If there are delays in mail order;
If the prescription drug arrives in an unusable condition; or
If the prescription drug does not arrive; and
Ensure patients have easy and timely access to prescription counseling by a pharmacist.
Subsection (1)(a) of this section does not apply to a health maintenance organization that is an integrated delivery system in which covered persons primarily use pharmacies that are owned and operated by the health maintenance organization.
For purposes of this section:
"Affiliated pharmacy" means a pharmacy that directly or indirectly through one or more intermediaries is owned by, controlled by, or is under common ownership or control of a pharmacy benefit manager, or where the pharmacy benefit manager has financial interest in the pharmacy.
"Covered person" means a person covered by a health plan including an enrollee, subscriber, policyholder, beneficiary of a group plan, or individual covered by any other health plan.
"Health benefit plan" means any entity or program that provides reimbursement for pharmaceutical services.
"Participating pharmacy" means a pharmacy that has entered into an agreement to provide prescription drugs to the pharmacy benefit manager's covered persons.
"Pharmacy network" means the pharmacies located in and licensed by the state and contracted by the pharmacy benefit manager to sell prescription drugs to covered persons.
"Specialty or limited distribution prescription drug" means a drug that's distribution is limited by a federal food and drug administration's element to assure safe use.
This section applies to health benefit plans issued or renewed on or after January 1, 2023.
[ 2021 c XXX § 1; ]**
** If a pharmacy benefit manager offers a distinct reimbursement to rural pharmacies, it shall provide a similar reimbursement to critical access pharmacies if the critical access pharmacy agrees to the terms and conditions set for affiliated pharmacies and the network as established by the health plan.
[ 2021 c XXX § 3; ]**