§ 54-52.1-04.15 — Health insurance benefits coverage - Prescription drug coverage - Transparency - Audits - Confidentiality

North Dakota § 54-52.1-04.15

• Jurisdiction: North Dakota
• Title 54: State Government
• Ch. 54-52.1: Uniform Group Insurance Program

Text

Transparency - Audits - Confidentiality.
1. If the prescription drug coverage component of a health insurance benefits coverage
contract received in response to a request for bids under section 54-52.1-04 utilizes
the services of a pharmacy benefits manager, either contracted directly with a
pharmacy benefits manager or indirectly through the health insurer, in addition to the
factors set forth under section 54-52.1-04 the board shall consider and give preference
to an insurer's contract that:
a. Provides the board or the board's auditor with a copy of the insurer's current
contract with the pharmacy benefits management company which controls the
prescriptions drug coverage offered as part of the health insurance benefits
coverage, and if the contract is revised or a new contract is entered, requires the
insurer to provide the board with the revision or new contract within thirty days of
the change.
b. Provides the board with monthly claims data and information on all programs
being implemented or modified, including prior authorization, step therapy,
mandatory use of generic drugs, or quantity limits.
c. Describes the extent to which the board may customize the benefit plan design,
including copayments, coinsurance, deductibles, and out-of-pocket limits; the
drugs that are covered; the formulary; and the member programs implemented.
d. Describes the audit rights of the board.
2. The board may conduct annual audits to the extent permitted under the contract terms
agreed to under subsection 1. The audits must include:
a. A review of a complete set of electronic prescription coverage claims data
reflecting all submitted claims, including information fields identified by the board.
b. A review of a list of all programs that have been implemented or modified during
the audit period under subsection 1, and in connection with each program the
auditor shall report on the cost, the cost savings or avoidance, member
disruption, the process for and number of overrides or approvals and
disapprovals, and clinical outcomes.
c. Recommendations for proposed changes to the prescription drug benefit
programs to decrease costs and improve plan beneficiaries' health care
treatment.
3. Information provided to the board under the contract provisions required under this
section are confidential; however, the board may disclose the information to retained
experts and the information retains its confidential status in the possession of these
experts.
4. The board may retain an auditor of the board's choice which is not a competitor of the
pharmacy benefits manager; a pharmaceutical manufacturer representative; or any
retail, mail, or specialty drug pharmacy representative or vendor.