With respect to a pharmacist or pharmacy, a pharmacy benefits manager, directly or through an affiliate or a contracted third party, may not do any of the following:
(1)Reimburse an in-network pharmacy or pharmacist in the state an amount less than the amount that the pharmacy benefits manager reimburses a similarly situated PBM affiliate for providing the same pharmacist services to covered individuals in the same health benefit plan.
(2)Practice spread pricing in this state unless required under the health benefit plan. If spread pricing is practiced pursuant to the health benefit plan, the pharmacy benefits manager shall submit an annual report to the commissioner which discloses the differences between the amount the health benefit plan is charged and the amount network pharmacies ar
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With respect to a pharmacist or pharmacy, a pharmacy benefits manager, directly or through an affiliate or a contracted third party, may not do any of the following:
(1) Reimburse an in-network pharmacy or pharmacist in the state an amount less than the amount that the pharmacy benefits manager reimburses a similarly situated PBM affiliate for providing the same pharmacist services to covered individuals in the same health benefit plan.
(2) Practice spread pricing in this state unless required under the health benefit plan. If spread pricing is practiced pursuant to the health benefit plan, the pharmacy benefits manager shall submit an annual report to the commissioner which discloses the differences between the amount the health benefit plan is charged and the amount network pharmacies are reimbursed.
(3) Deny a pharmacy or pharmacist the right to participate as a network provider if the pharmacy or pharmacist meets and agrees to the terms and conditions, including reimbursements, in the pharmacy benefits manager’s contract, including an independent pharmacy that qualifies for reimbursement at the minimum rate established in Section 27-45A-13(a)(1), notwithstanding any term to the contrary in the pharmacy benefits manager’s contract.
(4) Impose credentialing standards on a pharmacist or pharmacy beyond or more onerous than the licensing standards set by the Alabama State Board of Pharmacy or charge a pharmacy or pharmacist any fee in regard to, without limitation, network enrollment, network participation, credentialing or recredentialing, change of ownership, submission of claims, transmission of claims, adjudication of claims, claims processed through discount card programs, or otherwise, if not in conjunction with an audit conducted pursuant to Article 8, Chapter 23, Title 34; provided, however, this subdivision shall not prohibit a pharmacy benefits manager from setting minimum requirements for participating in a pharmacy network.
(5) Prohibit a pharmacist or pharmacy from providing a covered individual with any relevant information about a prescription drug, including the following:
a. The cost and reimbursement amount of the drug.
b. An alternative drug.
c. Any other information considered to be necessary in the professional judgment of the pharmacist.
(6) Prohibit a pharmacist or pharmacy from offering and providing delivery services to a covered individual as an ancillary service of the pharmacy, provided all of the following requirements are met:
a. The pharmacist or pharmacy can demonstrate quality, stability, and safety standards during delivery.
b. The pharmacist or pharmacy does not charge any delivery or service fee to a pharmacy benefits manager or health insurer.
c. The pharmacist or pharmacy alerts the covered individual that he or she will be responsible for any delivery service fee associated with the delivery service, and that the pharmacy benefits manager or health insurer will not reimburse the delivery service fee.
(7) Charge or hold a pharmacist or pharmacy responsible for a fee or penalty relating to an audit conducted pursuant to Article 8, Chapter 23, Title 34, provided this prohibition does not restrict recoupments made in accordance with the Pharmacy Audit Integrity Act.
(8) Charge a pharmacist or pharmacy a point-of-sale or retroactive fee or otherwise recoup funds from a pharmacy in connection with claims for which the pharmacy has already been paid, unless the recoupment is made pursuant to an audit conducted in accordance with Article 8, Chapter 23, Title 34.
(9) Except for a drug reimbursed, directly or indirectly, by the Medicaid program, vary the amount a pharmacy benefits manager reimburses an entity for a drug, including each and every prescription medication that is eligible for specialty tier placement by the Centers for Medicare and Medicaid Services pursuant to 42 C.F.R. § 423.560, regardless of any provision of law to the contrary, on the basis of whether:
a. The drug is subject to an agreement under 42 U.S.C. § 256b; or
b. The entity participates in the program set forth in 42 U.S.C. § 256b.
(10) If an entity participates, directly or indirectly, in the program set forth in 42 U.S.C. § 256b, do any of the following:
a. Assess a fee, charge-back, or other adjustment on the entity.
b. Restrict access to the pharmacy benefits manager’s pharmacy network.
c. Require the entity to enter into a contract with a specific pharmacy to participate in the pharmacy benefits manager’s pharmacy network.
d. Create a restriction or an additional charge on a patient who chooses to receive drugs from the entity.
e. Create any additional requirements or restrictions on the entity.
(11) Require a claim for a drug to include a modifier to indicate that the drug is subject to an agreement under 42 U.S.C. § 256b.
(12) Penalize or retaliate against a pharmacist or pharmacy for exercising rights under this chapter or Article 8, Chapter 23, Title 34. For purposes of this subdivision, the conduct prohibited includes any written or verbal communication that a reasonable individual would construe as a threat of penalty or retaliation received before or in the course of exercising rights under this chapter or Article 8, Chapter 23, Title 34.
(13) Prohibit a pharmacist or pharmacy from declining to dispense a drug to a covered individual, or directing a covered individual to another pharmacy, if the reimbursement amount would be lower than the dispensing cost of the pharmacist or pharmacy.
(14) Take retaliatory action against, or impose any penalty on, a pharmacist or pharmacy who declines to dispense a drug to a covered individual under subdivision (13), including cancellation or nonrenewal of a contract, or suit for breach of contract.