A pharmacy benefits manager may not do any of the following:

(1) Reimburse an in-network pharmacy or pharmacist in the state an amount less than the amount that the pharmacy benefits manager reimburses a similarly situated PBM affiliate for providing the same pharmacist services to covered individuals in the same health benefit plan.

Terms Used In Alabama Code 27-45A-10

  • Contract: A legal written agreement that becomes binding when signed.
  • following: means next after. See Alabama Code 1-1-1
  • state: when applied to the different parts of the United States, includes the District of Columbia and the several territories of the United States. See Alabama Code 1-1-1
(2) Deny a pharmacy or pharmacist the right to participate as a contract provider if the pharmacy or pharmacist meets and agrees to the terms and conditions, including reimbursements, in the pharmacy benefits manager’s contract.
(3) Impose credentialing standards on a pharmacist or pharmacy beyond or more onerous than the licensing standards set by the Alabama State Board of Pharmacy or charge a pharmacy a fee in connection with network enrollment, provided this subdivision shall not prohibit a pharmacy benefits manager from setting minimum requirements for participating in a pharmacy network.
(4) Prohibit a pharmacist or pharmacy from providing a covered individual specific information on the amount of the covered individual’s cost share for the covered individual’s prescription drug and the clinical efficacy of a more affordable alternative drug if one is available, or penalize a pharmacist or pharmacy for disclosing this information to a covered individual or for selling to a covered individual a more affordable alternative if one is available.
(5) Prohibit a pharmacist or pharmacy from offering and providing delivery services to a covered individual as an ancillary service of the pharmacy, provided all of the following requirements are met:

a. The pharmacist or pharmacy can demonstrate quality, stability, and safety standards during delivery.
b. The pharmacist or pharmacy does not charge any delivery or service fee to a pharmacy benefits manager or health insurer.
c. The pharmacist or pharmacy alerts the covered individual that he or she will be responsible for any delivery service fee associated with the delivery service, and that the pharmacy benefits manager or health insurer will not reimburse the delivery service fee.
(6) Charge or hold a pharmacist or pharmacy responsible for a fee or penalty relating to an audit conducted pursuant to The Pharmacy Audit Integrity Act, Article 8 of Chapter 23 of Title 34, provided this prohibition does not restrict recoupments made in accordance with the Pharmacy Audit Integrity Act.
(7) Charge a pharmacist or pharmacy a point-of-sale or retroactive fee or otherwise recoup funds from a pharmacy in connection with claims for which the pharmacy has already been paid, unless the recoupment is made pursuant to an audit conducted in accordance with the Pharmacy Audit Integrity Act.
(8) Except for a drug reimbursed, directly or indirectly, by the Medicaid program, vary the amount a pharmacy benefits manager reimburses an entity for a drug, including each and every prescription medication that is eligible for specialty tier placement by the Centers for Medicare and Medicaid Services pursuant to 42 C.F.R. § 423.560, regardless of any provision of law to the contrary, on the basis of whether:

a. The drug is subject to an agreement under 42 U.S.C. § 256b; or
b. The entity participates in the program set forth in 42 U.S.C. § 256b.
(9) If an entity participates, directly or indirectly, in the program set forth in 42 U.S.C. § 256b, do any of the following:

a. Assess a fee, charge-back, or other adjustment on the entity.
b. Restrict access to the pharmacy benefits manager’s pharmacy network.
c. Require the entity to enter into a contract with a specific pharmacy to participate in the pharmacy benefits manager’s pharmacy network.
d. Create a restriction or an additional charge on a patient who chooses to receive drugs from the entity.
e. Create any additional requirements or restrictions on the entity.
(10) Require a claim for a drug to include a modifier to indicate that the drug is subject to an agreement under 42 U.S.C. § 256b.
(11) Penalize or retaliate against a pharmacist or pharmacy for exercising rights under this chapter or the Pharmacy Audit Integrity Act.
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