1.A pharmacy benefits manager shall not do any of the following:
a.If a pharmacy or pharmacist has agreed to participate in a covered person’s health
benefit plan, prohibit or limit the covered person from selecting a pharmacy or pharmacist
of the covered person’s choice, or impose a monetary advantage or penalty that would
affect a covered person’s choice. A monetary advantage or penalty includes a copayment
or coinsurance variation, a reduction in reimbursement for services, a promotion of one
participating pharmacy over another, or comparing the reimbursement rates of a pharmacy
against mail order pharmacy reimbursement rates.
b.Deny a pharmacy or pharmacist the right to participate as a contract provider under a
health benefit plan if the pharmacy or pharmacist agrees to provide pha
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1. A pharmacy benefits manager shall not do any of the following:
a. If a pharmacy or pharmacist has agreed to participate in a covered person’s health
benefit plan, prohibit or limit the covered person from selecting a pharmacy or pharmacist
of the covered person’s choice, or impose a monetary advantage or penalty that would
affect a covered person’s choice. A monetary advantage or penalty includes a copayment
or coinsurance variation, a reduction in reimbursement for services, a promotion of one
participating pharmacy over another, or comparing the reimbursement rates of a pharmacy
against mail order pharmacy reimbursement rates.
b. Deny a pharmacy or pharmacist the right to participate as a contract provider under a
health benefit plan if the pharmacy or pharmacist agrees to provide pharmacy services that
meet the terms and requirements of the health benefit plan and the pharmacy or pharmacist
agreestothetermsofreimbursementsetforthbythethird-partypayorforsimilarlyclassified
pharmacies.
c. Impose upon a pharmacy or pharmacist, as a condition of participation in a third-party
payor network, any course of study, accreditation, certification, or credentialing that is
inconsistent with, more stringent than, or in addition to state requirements for licensure or
certification, and the administrative rules adopted by the board of pharmacy.
d. Unreasonably designate a prescription drug as a specialty drug to prevent a covered
person from accessing the prescription drug, or limiting a covered person’s access to the
prescription drug, from a pharmacy or pharmacist that is within the health carrier’s network.
A covered person or pharmacy harmed by an alleged violation of this paragraph may file a
complaint with the commissioner, and the commissioner shall, in consultation with the board
of pharmacy, make a determination as to whether the covered prescription drug meets the
definition of a specialty drug.
e. Require a covered person, as a condition of payment or reimbursement, to purchase
pharmacy services, including prescription drugs, exclusively through a mail order pharmacy.
f. Impose upon a covered person a copayment, reimbursement amount, number of days
of a prescription drug supply for which reimbursement will be allowed, or any other payment
or condition relating to purchasing pharmacy services from a pharmacy that is more costly or
restrictive than would be imposed upon the covered person if such pharmacy services were
purchased from a mail order pharmacy, or any other pharmacy that can provide the same
pharmacy services for the same cost and copayment as a mail order service.
2. a. If a third-party payor providing reimbursement to covered persons for prescription
drugs restricts pharmacy participation, the third-party payor shall notify, in writing, all
pharmacies within the geographical coverage area of the health benefit plan restriction, and
offer the pharmacies the opportunity to participate in the health benefit plan at least sixty
days prior to the effective date of the health benefit plan restriction. All pharmacies in the
geographical coverage area of the health benefit plan shall be eligible to participate under
identical reimbursement terms for providing pharmacy services and prescription drugs.
b. The third-party payor shall inform covered persons of the names and locations of all
pharmacies participating in the health benefit plan as providers of pharmacy services and
prescription drugs.
5 REGULATION OF PHARMACY BENEFITS MANAGERS, §510B.8
c. A participating pharmacy shall be entitled to announce to the pharmacy’s customers
that the pharmacy participates in the health benefit plan.
3. The commissioner shall not certify a pharmacy benefits manager or license an
insurance producer that is not in compliance with this section.
4. A covered person or pharmacy injured by a violation of this section may maintain a
cause of action to enjoin the continuation of the violation.