1135B 98th Legislative Session 1135
AMENDMENT 1135B
FOR
THE INTRODUCED BILL
Introduced by: Representative Weisgram
An Act to provide for transparency in the pricing of prescription drugs.
Be it enacted by the Legislature of the State of South Dakota:
Section 1. That § 58-29E-1 be AMENDED:
58-29E-1. Terms used in this chapter mean:
(1) "Covered
entity," a nonprofit hospital or medical service corporation,
health insurer, health benefit plan, or health maintenance
organization; a health program administered by a department or the
state in the capacity of provider of health coverage; or an employer,
labor union, or other group of persons organized in the state that
provides health coverage to covered individuals who are employed or
reside in the state. The term does not include a self‑funded
plan that is exempt from state regulation pursuant to ERISA, a plan
issued for coverage for federal employees, or a health plan that
provides coverage only for accidental injury, specified disease,
hospital indemnity, medicare supplement, disability income, long‑
term care, or other limited benefit health insurance policies and
contracts;
"Brand name," the
proprietary or registered trademark name given to a drug product by
its manufacturer, labeler, or distributor and placed on the drug or
on its container, label, or wrapping, at the time of packaging
the same as set forth in § 36-11-2;
(2) "Covered individual,"
a member, participant, enrollee, contract holder, policy holder, or
beneficiary of a
covered entity
third-party payor
who is provided health coverage by the
covered entity
third-party payor.
The term includes a dependent or other person
individual
provided health
coverage through a policy, contract, or plan for a covered
individual;
(3) "Director,"
the director of the Division of Insurance;
(4) "Generic
drug," a chemically equivalent copy of a brand‑
name drug with
an expired patent;
(5) "Labeler,"
an entity or person that receives prescription drugs from a
manufacturer or wholesaler and repackages those drugs for later
retail sale and that has a labeler code from the federal Food and
Drug Administration under 21 C.F.R. § 270.20 (1999);
(4) "Health
benefit plan," a
policy, contract, certificate, or agreement entered into, offered, or
issued by a health carrier to provide, deliver, arrange for, pay for,
or reimburse any of the costs of health care services, provided the
term includes short-term and catastrophic health insurance policies,
and a policy that pays on a cost-incurred basis, except as otherwise
specifically exempted in this definition, and further provided that
the term does not include:
(a) Coverage only for accident, or
disability income insurance, or any combination thereof; coverage
issued as a supplement to liability insurance; liability insurance,
including general liability insurance and automobile liability
insurance; workers' compensation or similar insurance; automobile
medical payment insurance; credit-only insurance; coverage for
on-site medical clinics; and other similar insurance coverage,
specified in federal regulations issued pursuant to Public Law
104-191, as of January 1, 2011, under which benefits for medical care
are secondary or incidental to other insurance benefits;
(b) The following benefits, if the
benefits are provided under a separate policy, certificate, or
contract of insurance or are otherwise not an integral part of the
plan: limited scope dental or vision benefits; benefits for long-term
care, nursing home care, home health care, community-based care, or
any combination thereof; or other similar, limited benefits specified
in federal regulations issued pursuant to Public Law 104-191, as of
January 1, 2011;
(c) The following benefits, if the
benefits are provided under a separate policy, certificate, or
contract of insurance, there is no coordination between the provision
of the benefits and any exclusion of benefits under any group health
plan maintained by the same plan sponsor, and the benefits are paid
with respect to an event without regard to whether benefits are
provided with respect to such an event under any group health plan
maintained by the same plan sponsor: coverage only for a specified
disease or illness; or hospital indemnity or other fixed indemnity
insurance; or
(d) The following, if offered as a
separate policy, certificate, or contract of insurance: Medicare
supplemental health insurance, as defined under 42 U.S.C. §
1395ss, as of January 1, 2011; coverage supplemental to the coverage
provided under 10 U.S.C. ch. 55, as of January 1, 2011; or similar
supplemental coverage provided to coverage under a group health plan
the same as set forth in § 58-17F-2;
(5) "Health
carrier," an
entity that is subject to the insurance laws and rules of this state,
or subject to the jurisdiction of the director of the Division of
Insurance, and which contracts or offers to contract, or enters into
an agreement to provide, deliver, arrange for, pay for, or reimburse
any of the costs of health care services, including a sickness and
accident insurance company, a health maintenance organization, a
nonprofit hospital and health service corporation, or any other
entity providing a plan of health insurance, health benefits, or
health services
the same as set forth in § 58-17F-1;
(6) "Interchangeable
biological product,"
a biological product that the U.S.
Food and Drug Administration has:
(a) Licensed, and has determined
meets the standards for interchangeability, pursuant to 42 U.S.C. §
262(k)(4), as of January 1, 2018; or
(b) Determined is therapeutically
equivalent, as set forth in the latest edition of, or any supplement
to, the Food and Drug Administration's publication entitled Approved
Drug Products with Therapeutic Equivalence Evaluations, as adopted by
the State Board of Pharmacy, in rules promulgated pursuant to chapter
1-26
the same as set forth in § 36-11-2;
(7) "Maximum allowable cost," the maximum amount that a pharmacy may be reimbursed, as set by a pharmacy benefit manager or a third-party payor, for a brand name or a generic drug, an interchangeable biological product, or any other prescription drug and which may include:
(a) The average acquisition cost;
(b) The national average acquisition cost;
(c) The average manufacturer price;
(d) The average wholesale price;
(e) The brand effective rate;
(f) The generic effective rate;
(g) Discount indexing;
(h) Federal upper limits;
(i) The wholesale acquisition cost; and
(j) Any other term used by a pharmacy benefit manager or a health carrier to establish reimbursement rates for a pharmacy.
(8) "Maximum allowable cost list," a list of prescription drugs that:
(a) Includes the maximum allowable cost for each prescription drug; and
(b) Is used, directly or indirectly, by a pharmacy benefit manager;
(9) "Pharmaceutical manufacturer," any person engaged in the business of preparing, producing, converting, processing, packaging, labeling, or distributing a prescription drug, but not including a wholesale distributor or dispenser;
(10) "Pharmacist,"
an
individual licensed by the State Board of Pharmacy, in accordance
with chapter 36-11,
to engage in the practice of pharmacy
the same as set forth in § 36-11-2;
(11) "Pharmacy,"
a place
that:
(a) Is
licensed by the State Board of Pharmacy, in accordance with chapter
36-11;
(b) Is
located within or outside of this state; and
(c) Provides
for the dispensing of drugs and rendering of pharmaceutical care to
residents of this state
the same as set forth in § 36-11-2;
(6)(12) "Pharmacy
benefits
benefit
management,"
the procurement of prescription drugs at a negotiated rate for
dispensation within this state to covered individuals, the
administration or management of prescription drug benefits provided
by a covered
entity third-party
payor for the
benefit of covered individuals, or any of the following services
provided with regard to the administration of the
following pharmacy
benefits:
(a) Mail service pharmacy;
(b) Claims processing, retail network management, and payment of claims to pharmacies for prescription drugs dispensed to covered individuals;
(c) Clinical formulary development and management services;
(d) Rebate contracting and administration;
(e) Certain patient compliance, therapeutic intervention, and generic substitution programs; and
(f) Disease management programs involving prescription drug utilization;
(7)(13) "Pharmacy
benefit management fee," a fee that covers the cost of providing
pharmacy benefit management, but does not exceed the value of the
service performed by the pharmacy benefit manager;
(14) "Pharmacy
benefits
benefit
manager,"
an
entity a
person that
performs pharmacy benefits
benefit
management.
The term,
pursuant to a contract or other relationship with a third-party payor
and includes
a:
(a) A
person or
entity acting
for
a pharmacy benefits manager in
a contractual or employment relationship in
the performance of for
a pharmacy benefit manager while providing pharmacy
benefits
benefit
management for
a covered
entitythird
party payor;
and includes
mail
(b) A
mail service
pharmacy.
The term does not include a health carrier licensed pursuant to Title
58 when the health carrier or its subsidiary is providing pharmacy
benefits management to its own insureds; or a public self‑funded
pool or a private single employer self‑funded plan that
provides such benefits or services directly to its beneficiaries;
(8)(15) "Pharmacy
benefit manager affiliate," a pharmacy that, or a pharmacist
who, directly or indirectly, through one or more intermediaries, owns
or controls, is owned and controlled by, or is under common ownership
or control of, a pharmacy benefit manager;
(16) "Pharmacy
benefit manager duty," a duty imposed upon a pharmacy benefit
manager to provide to the Division of Insurance, during any action
under section 18 of this Act:
(a) The
amount charged or claimed by the pharmacy benefit manager in a format
that allows the division to identify all instances of spread pricing;
and
(b) Information
regarding shared ownership interest, by any person defined in this
section;
(17) "Pharmacy
network," pharmacies that have contracted with a pharmacy
benefit manager to dispense or sell prescription drugs to individuals
covered
individuals under a health benefit plan for which the prescription
drug benefit is managed by a pharmacy benefit manager;
(18)(17) "Prescription
drug," a drug classified by the United States Food and Drug
Administration as requiring a prescription by a health care
practitioner, prior to being administered or dispensed to a patient,
and including interchangeable biological products, brand names, and
generic drugs;
(19)(18) "Prescription
drug benefit,” a health benefit plan providing third-party
payment or prepayment for prescription drugs;
(20)(19) "Prescription
drug order,” a
practitioner's written or oral order, for a drug or a drug device,
for a specific patient
the same as set forth in § 36-11-2;
(21)(20) "Proprietary
information," information on pricing, costs, revenue, taxes,
market share, negotiating strategies, customers, and personnel held
by a
private
entities
entity
and used for
that private entity's business purposes;
(9)(22)(21)
"Rebate," a discount or other negotiated price concession
that is paid directly or indirectly to a pharmacy benefit manager by
a pharmaceutical manufacturer or by an entity in the prescription
drug supply chain, other than a covered individual, and which is:
(a) Based on a pharmaceutical manufacturer's list price for a prescription drug;
(b) Based on utilization;
(c) Designed to maintain, for the pharmacy benefit manager, a net price for a prescription drug, during a specified period of time, in the event the pharmaceutical manufacturer's list price increases; or
(d) Based on estimates regarding the quantity of a prescribed drug that will be dispensed by a pharmacy to covered individuals;
(23)(22) "Spread
pricing," an amount charged or claimed by a pharmacy benefit
manager that is in excess of the ingredient cost for a dispensed
prescription drug, plus a dispensing fee paid directly or indirectly
to a pharmacy, pharmacist, or other provider, on behalf of the
third-party payor, less a pharmacy benefit management fee;
(24)(23) "Third-party
payor," any entity, other than a covered individual, a covered
individual's representative, or a healthcare provider, which is
responsible for any amount of reimbursement for a prescription drug
benefit, provided the term includes a health carrier and a health
benefit plan;
(25)(24) "Trade
secret,"
information, including a formula, pattern, compilation, program,
device, method, technique, or process, that:
(a) Derives
independent economic value, actual or potential, from not being
generally known to, and not being readily ascertainable by proper
means by, other persons who can obtain economic value from its
disclosure or use; and
(b) Is
the subject of efforts that are reasonable under the circumstances to
maintain its secrecy
the same as set forth in § 37-29-1;
(26)(25) "Unaffiliated
pharmacy," a dispensing pharmacy that is not:
(a) Owned, in whole or in part, by a pharmacy benefit manager;
(b) A subsidiary of a pharmacy benefit manager; or
(c) An affiliate of a pharmacy benefit manager; and
(27)(26) "Wholesale
distributor,"
any person engaged in wholesale distribution, but not including:
(a) A
manufacturer;
(b) A
manufacturer's co-licensed partner;
(c) A
repackager; or
(d) A
third-party logistics provider
the same as set forth in § 36-11A-25.
Section 2. That § 58-29E-2 be AMENDED:
58-29E-2.
No
A
person or
entity may
perform
or
not act as a
pharmacy benefits
benefit
manager in this
state without a valid
license
to operate as a third party administrator pursuant to chapter 58-29D.
Sections 58-29D-26,
58-29D-27,
and 58-29D-29
do not apply to pharmacy benefits managers.
Section 3. That § 58-29E-3 be AMENDED:
58-29E-3.
Each pharmacy
benefits
benefit
manager shall
perform its duties exercising
in
good faith and
with
fair dealing
toward the covered
entity third-party
payor.
Section 4. That § 58-29E-4 be AMENDED:
58-29E-4.
A covered
entity third-party
payor may
request that any
a
pharmacy
benefits
benefit
manager,
with which it has a pharmacy benefits
benefit
management
services contract,
disclose to the covered
entity,third-party
payor the
amount of all rebate revenues and the nature, type, and amounts of
all other revenues that the pharmacy benefits
benefit
manager
receives from each pharmaceutical manufacturer or
labeler with
whom
which
the pharmacy
benefits
benefit
manager has a
contract.The
Annually,
at the time of contract renewal, the pharmacy
benefits
benefit
manager shall
disclose in writing:
(1) The aggregate amount, and for
a list of drugs to be specified in the contract, the specific amount,
of all rebates and other retrospective utilization discounts that
are received by
the pharmacy benefits
benefit
manager,
directly or indirectly, from each pharmaceutical manufacturer
or labeler that,
and which are
earned in connection with the dispensing of prescription drugs to
covered individuals of the health benefit plans issued by the covered
entity third-party
payor or for
which the covered
entity third-party
payor is the
designated administrator;
(2) The nature, type, and amount
of all other revenue received by the pharmacy benefits
benefit
manager,
directly or indirectly,
from each pharmaceutical manufacturer or
labeler,
for any other
products or services,
provided to the pharmaceutical manufacturer or
labeler by
the pharmacy benefits
benefit
manager,
with respect to programs that the covered
entity third-party
payor offers or
provides to its enrolleescovered
individuals;
and
(3) Any prescription drug
utilization information requested by the covered
entitythird-party
payor and
relating to covered individuals.
A pharmacy benefits
benefit
manager shall,
within thirty days,
provide such
the
information
requested by
the covered entity for such disclosure within thirty days of receipt
of the requestin
accordance with this section.
If requested, the information
shall
must
be provided no
less than once each year.
The contract entered into between
the pharmacy benefits
benefit
manager and the
covered
entity shall third-party
payor must set
forth any fees to be charged for drug utilization reports requested
by the
covered entity
third-party payor.
Section 5. That § 58-29E-5 be AMENDED:
58-29E-5.
A pharmacy
benefits
benefit
manager, unless
authorized pursuant to the terms of its contract with a covered
entitythird-party
payor, may not
contact any covered individual,
without the
express written
permission of the covered
entitythird-party
payor.
Section 6. That § 58-29E-6 be AMENDED:
58-29E-6.
Except for
utilization information, a covered
entitythird-party
payor shall
maintain any
information
disclosed in response to a request
pursuant to
under
§ 58-29E-4
as confidential and proprietary information, and may not use such
that
information for
any other purpose or disclose such
that
information to
any other person,
except as provided in this chapter or in the pharmacy benefits
benefit
management
services contract between the parties.
Any
covered entity whoA
third-party payor that
discloses information,
in violation of this section,
is subject to an action for injunctive relief and is liable for any
damages which
that
are the direct
and proximate result of such
the
disclosure.
Nothing in this section prohibits
a covered
entity third-party
payor from
disclosing confidential or proprietary information to the director
of the Division of Insurance,
upon request. Any
such informationInformation
obtained by the director
in accordance with this section
is confidential and privileged,
and is not open to public inspection or disclosure.
Section 7. That § 58-29E-7 be AMENDED:
58-29E-7.
The
covered entity may have the pharmacy benefits manager's books and
records related to the rebates or other information described in
subdivisions 58-29E-4(1),
(2), and (3), to the extent the information relates directly or
indirectly to such covered entity's contract, audited in accordance
with the terms of the pharmacy benefits management services contract
between the parties. However, if the parties have not expressly
provided for audit rights and the pharmacy benefits manager has
advised the covered entity that other reasonable options are
available and subject to negotiation, the covered entity may have
such books and records audited as follows:
(1) Such
audits may be conducted no more frequently than once in each
twelve‑month period upon not less than thirty business days'
written notice to the pharmacy benefits manager;
(2) The
covered entity may select an independent firm to conduct such audit,
and such independent firm shall sign a confidentiality agreement with
the covered entity and the pharmacy benefits manager ensuring that
all information obtained during such audit will be treated as
confidential. The firm may not use, disclose, or otherwise reveal any
such information in any manner or form to any person or entity except
as otherwise permitted under the confidentiality agreement. The
covered entity shall treat all information obtained as a result of
the audit as confidential, and may not use or disclose such
information except as may be otherwise permitted under the terms of
the contract between the covered entity and the pharmacy benefits
manager or if ordered by a court of competent jurisdiction for good
cause shown;
(3) Any
such audit shall be conducted at the pharmacy benefits manager's
office where such records are located, during normal business hours,
without undue interference with the pharmacy benefits manager's
business activities, and in accordance with reasonable audit
procedures.
A third-party payor that has contracted with a licensed pharmacy benefit manager may audit the pharmacy benefit manager once each calendar year. The audit authorized by this section is in addition to any other statutory or contractual audit rights. As part of the audit, a third-party payor may request:
(1) All reimbursements paid to retail pharmacies, on a claim level, for all customers of the pharmacy benefit manager in this state, including ancillary charges, claw backs, dispensing fees, drug-specific reimbursements, other fees, rebates, and reimbursement adjustments;
(2) Differences in reimbursement amounts paid to affiliated and unaffiliated pharmacies, including differences in dispensing fees and reimbursed ingredient costs;
(3) Historical claims data, including:
(a) Acquisition costs;
(b) Administrative fees associated with claims;
(c) Amounts paid by a covered individual;
(d) Amounts paid by a third-party payor;
(e) Channels, whether mail or retail;
(f) Dispensing fees;
(g) Formulary tiers;
(h) Ingredient costs;
(i) Ingredient quantity;
(j) Sales tax;
(k) Supply availability by the number of days; and
(l) Usual and customary prices; and
(4) Aggregate rebate amounts, received by calendar quarter, directly or indirectly from manufacturers, including rebates from other entities affiliated with or related to the pharmacy benefit manager, if those entities negotiate or contract with manufacturers.
A pharmacy benefit manager shall, within thirty days, provide the information requested in accordance with this section, together with a certification, signed by the chief executive officer or the chief financial officer of the pharmacy benefit manager, attesting to the accuracy and completeness of the information.
Section 8. That chapter 58-29E be amended with a NEW SECTION:
A
Except
as provided in chapter 58-17K,
and in accordance with the audit provisions in § 58-29E-7,
a third-party payor that has contracted with a licensed pharmacy
benefit manager may not publish, or directly or indirectly disclose:
(1) Any information that reveals the identity of a specific third-party payor or manufacturer;
(2) Prices charged for a specific drug or class of drugs;
(3) The amount of any rebates provided for a specific drug or class of drugs; or
(4) Any information that has the potential to compromise the financial, competitive, or proprietary nature of the pharmacy benefit manager's business.
The
information referenced in this
section §
58-29E-7
is protected from disclosure as confidential and proprietary. The
information is privileged and not open to public inspection or
disclosure.
A
third-party payor that has contracted with a licensed pharmacy
benefit manager shall impose the confidentiality protections set
forth in
this section
§ 58-29E-7
on any vendor or third party that may receive or have access to the
information.
Section 9. That § 58-29E-8 be AMENDED:
58-29E-8.
With
regard to the dispensation of a substitute prescription drug for a
prescribed drug to a covered individual, when the pharmacy benefits
manager requests a substitution, the following provisions apply:
(1) TheA
pharmacy
benefits
benefit
manager may
request the
substitution of that
a lower‑priced
generic and therapeutically equivalent prescription
drug
be dispensed to a covered individual, as a substitute
for a higher‑priced prescribed
prescription
drug;
(2) With
regard to substitutions in which.
If
the substitute prescription
drug's net cost
is more
higher
for the covered
individual or the covered
entitythird-party
payor than the
originally
prescribed drug, the substitution must
may
be made only
for medical reasons that benefit the covered individual.
If a substitution is being
requested pursuant to this subdivisionsection,
the pharmacy benefits
benefit
manager shall
must
obtain the
approval of the prescribing health professional.
Nothing in this section permits the substitution of an equivalent drug product contrary to § 36-11-46.2.
Section 10. That § 58-29E-8.1 be AMENDED:
58-29E-8.1.
A pharmacy
benefits
benefit
manager may
neither prohibit a
pharmacist or pharmacy from, nor
penalize a pharmacist or pharmacy for providing
cost-sharing information on the amount a covered individual may pay
for a particular,
informing
an a
covered individual about:
(1) The cost of a prescription drug;
(2) The amount of reimbursement that the pharmacy will receive for dispensing the prescription drug;
(3) The cost and clinical efficacy of a more affordable alternative prescription drug, if one is available; and
(4) Any
differential between the amount an
a
covered individual would pay under the covered individual’s
prescription drug benefit and a lower price the covered individual
would pay for the prescription drug, if the covered individual
obtained the prescription drug without making a claim for benefits on
the covered individual’s prescription drug benefit.
Section 11. That § 58-29E-10 be AMENDED:
58-29E-10.
Any
covered entityA
third-party payor
may bring a civil action to enforce the
provisions of this
chapter or to
seek civil
damages for the
a
violation of
its
provisionsthis
chapter.
Section 12. That § 58-29E-12 be AMENDED:
58-29E-12.
No
A
pharmacy
benefit manager shall
may
not contractually
require a pharmacy,
who
that is a
participating provider in a health
benefit plan
provided by a covered
entity, to charge
or
collect third-party
payor, from charging a covered individual or collecting from
an
insureda
covered individual
a cost share for a prescription drug
or pharmacy
service that exceeds the amount retained by the pharmacist or
pharmacy from all payment sources,
for the
filling of
the
prescription or providing the pharmacy service.
Section 13. That § 58-29E-13 be AMENDED:
58-29E-13.
No
A
pharmacy
benefit manager contracting
with a covered entity shallmay
not, directly or indirectly,
retroactively adjust a claim for reimbursement submitted by a
pharmacy for a prescription drug,
unless
the adjustment is a result of either of the following:
(1) A
The
adjustment is necessitated by a pharmacy
audit conducted in accordance with chapter 58-29F;or
(2) A
The
adjustment is necessitated by a technical
billing error;
(3) The original claim was found to have been fraudulently submitted; or
(4) The claim submission was a duplicate for which the pharmacy had already received payment.
Section 14. That chapter 58-29E be amended with a NEW SECTION:
A pharmacy benefit manager may not assess, charge, or collect, from a pharmacy or pharmacist, any remuneration or fee, including:
(1) An accreditation fee;
(2) A brand effective rate fee;
(3) A claim processing fee;
(4) A credentialing fee;
(5) A dispensing fee;
(6) An effective rate fee;
(7) A generic effective rate fee;
(8) A pharmacy network participation fee; and
(9) A performance-based fee.
Section 15. That chapter 58-29E be amended with a NEW SECTION:
Prior to placing a prescription drug on a maximum allowable cost list, a pharmacy benefit manager shall ensure that the prescription drug is:
(1) Listed as therapeutically and pharmaceutically equivalent in the latest edition of, or any supplement to, the Food and Drug Administration's publication entitled Approved Drug Products with Therapeutic Equivalence Evaluations, as adopted by the State Board of Pharmacy, in rules promulgated pursuant to chapter 1-26;
(2) Not obsolete or temporarily unavailable; and
(3) Available for purchase, without limitation, by every pharmacy in this state, from a national or regional wholesale distributor licensed in this state.
Section 16. That chapter 58-29E be amended with a NEW SECTION:
A pharmacy benefit manager shall:
(1) Provide each pharmacy in a pharmacy network with reasonable access to each maximum allowable cost list to which the pharmacy is subject;
(2) Update a maximum allowable cost list, within seven calendar days from the date of any increase, at or above ten percent, in the price charged for a prescription drug on the list by one or more wholesale distributors doing business in this state;
(3) Update the maximum allowable cost list, within seven calendar days from the date of any change in the methodology, or any change in the value of a variable applied in the methodology, on which the maximum allowable cost list is based; and
(4) Provide a process under which each pharmacy in a pharmacy network may receive prompt notice of any change in a maximum allowable cost list to which the pharmacy is subject.
Section 17. That chapter 58-29E be amended with a NEW SECTION:
A pharmacy benefit manager may not reimburse any pharmacy located in this state an amount that is less than that which the pharmacy benefit manager reimburses a pharmacy benefit manager affiliate for dispensing the same prescription drug as that dispensed by the pharmacy.
The reimbursement amount must be calculated on a per unit basis, using the same generic product identifier or generic code number.
Section 18. That chapter 58-29E be amended with a NEW SECTION:
The
director of the Division of Insurance may deny an application for
licensure as a pharmacy benefit manager, may deny an application for
the renewal of a pharmacy benefit manager license, and may suspend or
revoke the license of a pharmacy benefit manager, if the director
determines that the pharmacy benefit manager:
(1) Is
in an unsound financial condition;
(2) Is
using methods or practices that are potentially hazardous or
injurious to covered individuals, third-party payors, or providers;
(3) Has
failed to pay, within sixty days, any final judgment entered against
it;
(4) Has
violated any statute or rule, or an order of the director;
(5) Has refused:
(a) To be examined;
(b) To produce its accounts,
records, and files for examination; or
(c) To provide information regarding
its business or any duties set forth in this chapter;
(6) Has, without just cause:
(a) Refused to pay proper claims or
perform services arising under its contracts;
(b) Required providers to accept
less than the amount due them; or
(c) Required covered individuals to
threaten or initiate legal action in order to secure their full
payment or the settlement of their claims;
(7) Is affiliated with or under the
same general management or interlocking directorate or ownership as
another pharmacy benefit manager that transacts business in this
state without a license;
(8) Fails to meet or continue
meeting any qualification required for the issuance of an initial
license;
(9) Has been convicted of, or has
entered a plea of guilty or nolo contendere to, a felony, without
regard to whether adjudication was withheld;
(10) Has a license that is under
suspension or revocation in another state; or
(11) Has provided false or
misleading information to the director
A pharmacy benefit manager licensed under this chapter shall, at the request of the Division of Insurance, provide:
(1) The amount charged or claimed by the pharmacy benefit manager, in a format that allows the division to identify all instances of spread pricing; and
(2) Information regarding a shared ownership interest by any person defined in § 58-29E-1.
Section 19. That chapter 58-29E be amended with a NEW SECTION:
In addition to any grounds set forth in § 58-29D-31, the director may deny a pharmacy benefit manager's application for an initial or a renewed license, and may suspend or revoke a pharmacy benefit manager's license, if the director determines that the pharmacy benefit manager, or an applicant for a license, failed to provide information as required by this chapter.
Section 20. That § 58-29E-11 be REPEALED:
The provisions of this
chapter apply only to pharmacy benefits management services contracts
entered into or renewed after June 30, 2004.
Underscores indicate new language.
Overstrikes
indicate deleted language.