§4349. Oversight and contracting responsibilities

(CONTAINS TEXT WITH VARYING EFFECTIVE DATES)

(WHOLE SECTION TEXT EFFECTIVE 1/1/20)

1.  Compliance.  A carrier is responsible for monitoring all activities carried out by the carrier, or all activities carried out on behalf of the carrier by a pharmacy benefits manager if the carrier contracts with a pharmacy benefits manager, related to a carrier's prescription drug benefits and for ensuring that all requirements of this chapter are met.

[PL 2019, c. 469, §8 (NEW); PL 2019, c. 469, §9 (AFF).]

2.  Fiduciary duty.  A carrier that contracts with a pharmacy benefits manager to perform any activities related to the carrier's prescription drug benefits is responsible for ensuring that, under the contract, the pharmacy benefits manager acts as the carrier's agent and owes a fiduciary duty to the carrier in the pharmacy benefits manager's management of activities related to the carrier's prescription drug benefits.

[PL 2019, c. 469, §8 (NEW); PL 2019, c. 469, §9 (AFF).]

3.  Contract requirements.  A carrier may not enter into a contract or agreement or allow a pharmacy benefits manager or any person acting on the carrier's behalf to enter into a contract or agreement that prohibits a pharmacy provider from:

A. Providing a covered person with the option of paying the pharmacy provider's cash price for the purchase of a prescription drug and not filing a claim with the covered person's carrier if the cash price is less than the covered person's cost-sharing amount; or   [PL 2019, c. 469, §8 (NEW); PL 2019, c. 469, §9 (AFF).]

B. Providing information to a state or federal agency, law enforcement agency or the superintendent when such information is required by law.   [PL 2019, c. 469, §8 (NEW); PL 2019, c. 469, §9 (AFF).]

[PL 2019, c. 469, §8 (NEW); PL 2019, c. 469, §9 (AFF).]

4.  Excess payments at point of sale prohibited.  A carrier or pharmacy benefits manager may not require a covered person to make a payment at the point of sale for a covered prescription drug in an amount greater than the least of:

A. The applicable cost-sharing amount for the prescription drug;   [PL 2019, c. 469, §8 (NEW); PL 2019, c. 469, §9 (AFF).]

B. The amount a covered person would pay for the prescription drug if the covered person purchased the prescription drug without using a health plan or any other source of prescription drug benefits or discounts; and   [PL 2019, c. 469, §8 (NEW); PL 2019, c. 469, §9 (AFF).]

C. The total amount the pharmacy will be reimbursed for the prescription drug from the pharmacy benefits manager or carrier, including the cost-sharing amount paid by a covered person.   [PL 2019, c. 469, §8 (NEW); PL 2019, c. 469, §9 (AFF).]

[PL 2019, c. 469, §8 (NEW); PL 2019, c. 469, §9 (AFF).]

5.  Adequate network.  A carrier shall provide a reasonably adequate retail pharmacy network for the provision of prescription drugs for its covered persons. A mail order pharmacy may not be included in determining the adequacy of a retail pharmacy network. The superintendent may adopt rules as necessary to carry out the purposes of this subsection. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2‑A.

[PL 2019, c. 469, §8 (NEW); PL 2019, c. 469, §9 (AFF).]

SECTION HISTORY

PL 2019, c. 469, §8 (NEW). PL 2019, c. 469, §9 (AFF).