§ 27-1-24.5-19 — Equal access and incentives; prohibited acts

Indiana § 27-1-24.5-19

• Jurisdiction: Indiana
• Title 27: INSURANCE
• Art. 1: DEPARTMENT OF INSURANCE
• Ch. 24.5: Pharmacy Benefit Managers

Text

(a) A pharmacy benefit manager shall
provide equal access and incentives to all pharmacies within the
pharmacy benefit manager's network.
(b) A pharmacy benefit manager may not do any of the following:
(1) Condition participation in any network on accreditation,
credentialing, or licensing of a pharmacy, other than a license or
permit required by the Indiana board of pharmacy or other state
or federal regulatory authority for the services provided by the
pharmacy. However, nothing in this subdivision precludes the
department from providing credentialing or accreditation
standards for pharmacies.
(2) Discriminate against any pharmacy.
(3) Directly or indirectly retroactively deny a claim or aggregate
of claims after the claim or aggregate of claims has been
adjudicated, unless any of the following apply:
(A) The original claim was submitted fraudulently.
(B) The original claim payment was incorrect because the
pharmacy or pharmacist had already been paid for the drug.
(C) The pharmacist services were not properly rendered by the
pharmacy or pharmacist.
(4) Reduce, directly or indirectly, payment to a pharmacy for
pharmacist services to an effective rate of reimbursement,
including permitting an insurer or plan sponsor to make such a
reduction.
(5) Reimburse a pharmacy that is affiliated with the pharmacy
benefit manager, other than solely being included in the pharmacy
benefit manager's network, at a greater reimbursement rate than
other pharmacies in the same network.
(6) Impose limits, including quantity limits or refill frequency
limits, on a pharmacy's access to medication that differ from those
existing for a pharmacy benefit manager affiliate.
(7) Share any covered individual's information, including
de-identified covered individual information, received from a
pharmacy or pharmacy benefit manager affiliate, except as
permitted by the federal Health Insurance Portability and
Accountability Act (HIPAA) (P.L.104-191).
A violation of this subsection by a pharmacy benefit manager
constitutes an unfair or deceptive act or practice in the business of
insurance under IC 27-4-1-4.

Legislative History

As added by P.L.68-2020, SEC.1. Amended by P.L.32-2021, SEC.78; P.L.196-2021, SEC.22.