Utah § 31A-46-304 Claims practices.

Utah Statutes

§ 31A-46-304 — Claims practices.

Utah § 31A-46-304

Title 31AInsurance Code

Ch. 31A-46Pharmacy Benefits Act

Part 31A-46-3Operating Requirements

This text of Utah § 31A-46-304 (Claims practices.) is published on Counsel Stack Legal Research, covering Utah primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook

Utah Code Ann. § 31A-46-304 (2026).

Text

(1)A pharmacy benefit manager shall permit a pharmacy to collect the amount of a customer's cost share from any source.

(2)A pharmacy benefit manager may not deny or reduce a reimbursement to a pharmacy or a pharmacist after the adjudication of the claim, unless:

(2)(a) the pharmacy or pharmacist submitted the original claim fraudulently;

(2)(b) the original reimbursement was incorrect because:

(2)(b)(i) the pharmacy or pharmacist had already been paid for the pharmacy service; or

(2)(b)(ii) an unintentional error resulted in an incorrect reimbursement; or

(2)(c) the pharmacy service was not rendered by the pharmacy or pharmacist.

(3)Subsection (2) does not apply if:

(3)(a) any form of an investigation or audit of pharmacy records for fraud, waste, abuse, or other intentional misrepre

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(1) A pharmacy benefit manager shall permit a pharmacy to collect the amount of a customer's cost share from any source.
(2) A pharmacy benefit manager may not deny or reduce a reimbursement to a pharmacy or a pharmacist after the adjudication of the claim, unless:

(2)(a) the pharmacy or pharmacist submitted the original claim fraudulently;
(2)(b) the original reimbursement was incorrect because:
(2)(b)(i) the pharmacy or pharmacist had already been paid for the pharmacy service; or
(2)(b)(ii) an unintentional error resulted in an incorrect reimbursement; or
(2)(c) the pharmacy service was not rendered by the pharmacy or pharmacist.
(3) Subsection (2) does not apply if:

(3)(a) any form of an investigation or audit of pharmacy records for fraud, waste, abuse, or other intentional misrepresentation indicates that the pharmacy or pharmacist engaged in criminal wrongdoing, fraud, or other intentional misrepresentation; or
(3)(b) the reimbursement is reduced as the result of the reconciliation of a reimbursement amount under a performance contract if:
(3)(b)(i) the performance contract lays out clear performance standards under which the reimbursement for a specific drug may be increased or decreased; and
(3)(b)(ii) the agreement between the pharmacy benefit manager and the pharmacy or pharmacist explicitly states, in a separate document that is signed by the pharmacy benefit manager and the pharmacy or pharmacist, that the provisions of Subsection (2) do not apply.