Effective - 28 Aug 2020, 2 histories
376.387. Pharmacy benefits manager, limitations and restrictions — enforcement. — 1. For purposes of this section, the following terms shall mean:
(1) "Covered person", the same meaning as such term is defined in section 376.1257;
(2) "Health benefit plan", the same meaning as such term is defined in section 376.1350;
(3) "Health carrier" or "carrier", the same meaning as such term is defined in section 376.1350;
(4) "Pharmacy", the same meaning as such term is defined in chapter 338;
(5) "Pharmacy benefits manager", the same meaning as such term is defined in section 376.388.
2. No pharmacy benefits manager shall include a provision in a contract entered into or modified on or after August 28, 2018, with a pharmacy or pharmacist that requires a covered person to make a payment for a prescription drug at the point of sale in an amount that exceeds the lesser of:
(1) The copayment amount as required under the health benefit plan; or
(2) The amount an individual would pay for a prescription if that individual paid with cash.
3. A pharmacy or pharmacist shall have the right to provide to a covered person information regarding the amount of the covered person's cost share for a prescription drug, the covered person's cost of an alternative drug, and the covered person's cost of the drug without adjudicating the claim through the pharmacy benefits manager. Neither a pharmacy nor a pharmacist shall be proscribed by a pharmacy benefits manager from discussing any such information or from selling a more affordable alternative to the covered person.
4. No pharmacy benefits manager shall, directly or indirectly, charge or hold a pharmacist or pharmacy responsible for any fee amount related to a claim that is not known at the time of the claim's adjudication, unless the amount is a result of improperly paid claims or charges for administering a health benefit plan.
5. This section shall not apply with respect to claims under Medicare Part D, or any other plan administered or regulated solely under federal law, and to the extent this section may be preempted under the Employee Retirement Income Security Act of 1974 for self-funded employer-sponsored health benefit plans.
6. A pharmacy benefits manager shall notify in writing any health carrier with which it contracts if the pharmacy benefits manager has a conflict of interest, any commonality of ownership, or any other relationship, financial or otherwise, between the pharmacy benefits manager and any other health carrier with which the pharmacy benefits manager contracts.
7. The department of commerce and insurance shall enforce this section.
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(L. 2018 S.B. 826, A.L. 2020 H.B. 1682)