Pharmacy benefits manager network adequacy

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  1. (a) A pharmacy benefits manager shall provide:

    1. (1)

      1. (A) A reasonably adequate and accessible pharmacy benefits manager network for the provision of prescription drugs for a health benefit plan that shall provide for convenient patient access to pharmacies within a reasonable distance from a patient's residence.

      2. (B) A mail-order pharmacy shall not be included in the calculations determining pharmacy benefits manager network adequacy; and

    2. (2) A pharmacy benefits manager network adequacy report describing the pharmacy benefits manager network and the pharmacy benefits manager network's accessibility in this state in the time and manner required by rule issued by the State Insurance Department.

  2. (b)

    1. (1) A pharmacy benefits manager shall report to the Insurance Commissioner on a quarterly basis for each healthcare insurer the following information:

      1. (A) The aggregate amount of rebates received by the pharmacy benefits manager;

      2. (B) The aggregate amount of rebates distributed to the appropriate healthcare insurer;

      3. (C) The aggregate amount of rebates passed on to the enrollees of each healthcare insurer at the point of sale that reduced the enrollees’ applicable deductible, copayment, coinsurance, or other cost-sharing amount;

      4. (D) The individual and aggregate amount paid by the healthcare insurer to the pharmacy benefits manager for pharmacist services itemized by pharmacy, by product, and by goods and services; and

      5. (E) The individual and aggregate amount a pharmacy benefits manager paid for pharmacist services itemized by pharmacy, by product, and by goods and services.

    2. (2) The report required under subdivision (b)(1) of this section is:

      1. (A) Proprietary and confidential under § 23-61-107(a)(4) and § 23-61-207; and

      2. (B) Not subject to the Freedom of Information Act of 1967, § 25-19-101 et seq.

  3. (c) A pharmacy benefits manager is prohibited from conducting spread pricing in this state.


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