§2868. Pharmacy benefit manager; regulation by Louisiana Board of Pharmacy;
requirements for permitting
A. A pharmacy benefit manager shall obtain and maintain a permit from the Board
of Pharmacy if the pharmacy benefit manager administers, develops, maintains, performs,
or provides one or more of the following pharmacy services in this state or that affects one
or more beneficiaries of a pharmacy benefit management plan administered by the pharmacy
benefit manager:
(1)Adjudication of appeals or grievances related to prescription drug coverage.
(2)Disease management programs. For purposes of this Subsection, "disease
management program" means a program adopted to guide and care for beneficiaries with
chronic health problems to improve the quality of health care provided to them and preve
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§2868. Pharmacy benefit manager; regulation by Louisiana Board of Pharmacy;
requirements for permitting
A. A pharmacy benefit manager shall obtain and maintain a permit from the Board
of Pharmacy if the pharmacy benefit manager administers, develops, maintains, performs,
or provides one or more of the following pharmacy services in this state or that affects one
or more beneficiaries of a pharmacy benefit management plan administered by the pharmacy
benefit manager:
(1) Adjudication of appeals or grievances related to prescription drug coverage.
(2) Disease management programs. For purposes of this Subsection, "disease
management program" means a program adopted to guide and care for beneficiaries with
chronic health problems to improve the quality of health care provided to them and prevent
future need for medical resources by using an integrated comprehensive approach.
(3) Drug formularies. For purposes of this Subsection, "drug formulary" means a list
of prescription medications or pharmaceutical products developed and approved by each
health plan that may be dispensed to a beneficiary through participating pharmacies. A drug
formulary may also be referred to as a "preferred drug list", "prior authorization list", or
"pharmacopeia".
(4) Drug regimen reviews. For purposes of this Subsection, "drug regimen review"
means third-party review of all medications a beneficiary is currently using, whether
prescribed or over-the-counter, and administered by any method.
(5) Prescription drug management programs. For purposes of this Subsection,
"prescription drug management program" means a program developed and designed to
administer the prescription drug benefit as part of a health plan, and as part of such
administration a PBM may contract with pharmacies for implementation and dispensing
drugs in accordance with the program.
(6) Processing of prior authorization requests. For purposes of this Subsection,
"processing of prior authorization requests" means making a determination regarding
payment coverage based on an advance approval request submitted by a physician or other
healthcare provider before a specific procedure, service, device, supply, or medication is
delivered to the beneficiary.
(7) Quality care dosing services. For purposes of this Subsection, "quality care
dosing services" means electronically checking prescription medications before they are
filled at the pharmacy to ensure that the quantity and dosage is consistent with the
recommendations of the United States Food and Drug Administration and others.
(8) Step therapy procedures. For purposes of this Subsection, "step therapy
procedure" means protocols and policies that establish a specific sequence in which
prescription drugs for a medical condition are approved for coverage by a health plan for a
beneficiary which generally requires cheaper drugs to be used before more costly drugs. Step
therapy may also be referred to as "fail first" protocol.
(9) Utilization management and utilization reviews. For purposes of this Subsection,
"utilization management" and "utilization review" mean third-party review and approval of
appropriateness and necessity of care that a healthcare provider has indicated for a
beneficiary prior to delivery and coverage of such care.
(10) Any other act, service, operation, or transaction incidental to or forming a part
of the compounding, filling, dispensing, exchanging, giving, offering for sale, or selling
drugs, medicines, poisons, or devices in this state by pharmacists or pharmacies, pursuant to
a prescription or an order of physicians, dentists, veterinarians, or other licensed
practitioners, requiring, involving, or employing the science or art of any branch of the
pharmacy profession, study, or training.
B. Every pharmacy benefit manager permitted by the Board of Pharmacy shall abide
by the applicable provisions of the Louisiana Pharmacy Practice Act and the rules and
regulations of the Board of Pharmacy.
C.(1) A pharmacy benefit manager may file for a hearing conducted before an
independent third-party adjudicator with the division of administrative law upon notice from
the board that it intends to take adverse or disciplinary action against the pharmacy benefit
manager that may result in the suspension or termination of the pharmacy benefit manager's
permit. If the pharmacy benefit manager elects to file for a hearing with the division of
administrative law, the ruling of the administrative law judge shall be appealable by either
the pharmacy benefit manager or the board, whichever party does not prevail.
(2) Nothing in this Subsection shall be construed to prevent the pharmacy benefit
manager from proceeding with a hearing before the board as provided for in the
Administrative Procedure Act, nor shall anything in this Subsection be construed to prevent
the board from taking any other action provided for by law or rule that would not result in
suspension or termination of the pharmacy benefit manager's permit.