Indiana Code 27-1-24.5-19. Equal access and incentives; prohibited acts
(b) A pharmacy benefit manager may not do any of the following:
Terms Used In Indiana Code 27-1-24.5-19
- covered individual: means an individual who is entitled to coverage under a health plan. See Indiana Code 27-1-24.5-1
- Department: means "the department of insurance" of this state. See Indiana Code 27-1-2-3
- effective rate of reimbursement: includes the following:
Indiana Code 27-1-24.5-2
- equal access and incentives: means that a pharmacy benefit manager allows any willing pharmacy provider to participate as part of any of the pharmacy benefit manager's networks as long as the pharmacy provider agrees to the terms and conditions of the relevant contract applicable to any other pharmacy provider within that network. See Indiana Code 27-1-24.5-3
- Insurance: means a contract of insurance or an agreement by which one (1) party, for a consideration, promises to pay money or its equivalent or to do an act valuable to the insured upon the destruction, loss or injury of something in which the other party has a pecuniary interest, or in consideration of a price paid, adequate to the risk, becomes security to the other against loss by certain specified risks; to grant indemnity or security against loss for a consideration. See Indiana Code 27-1-2-3
- insurer: means a company, firm, partnership, association, order, society or system making any kind or kinds of insurance and shall include associations operating as Lloyds, reciprocal or inter-insurers, or individual underwriters. See Indiana Code 27-1-2-3
- pharmacist: means an individual licensed as a pharmacist under IC 25-26. See Indiana Code 27-1-24.5-9
- pharmacist services: means products, goods, and services provided as part of the practice of pharmacy. See Indiana Code 27-1-24.5-10
- pharmacy: means the physical location:
Indiana Code 27-1-24.5-11
- pharmacy benefit manager: means an entity that, on behalf of a health plan, state agency, insurer, managed care organization, or other third party payor:
Indiana Code 27-1-24.5-12
- pharmacy benefit manager affiliate: means a pharmacy or pharmacist that directly or indirectly, through one (1) or more intermediaries:
Indiana Code 27-1-24.5-13
(2) Discriminate against any pharmacy.
(3) Directly or indirectly retroactively deny a claim or aggregate of claims after the claim or aggregate of claims has been adjudicated, unless any of the following apply:
(A) The original claim was submitted fraudulently.
(B) The original claim payment was incorrect because the pharmacy or pharmacist had already been paid for the drug.
(C) The pharmacist services were not properly rendered by the pharmacy or pharmacist.
(4) Reduce, directly or indirectly, payment to a pharmacy for pharmacist services to an effective rate of reimbursement, including permitting an insurer or plan sponsor to make such a reduction.
(5) Reimburse a pharmacy that is affiliated with the pharmacy benefit manager, other than solely being included in the pharmacy benefit manager’s network, at a greater reimbursement rate than other pharmacies in the same network.
(6) Impose limits, including quantity limits or refill frequency limits, on a pharmacy’s access to medication that differ from those existing for a pharmacy benefit manager affiliate.
(7) Share any covered individual‘s information, including de-identified covered individual information, received from a pharmacy or pharmacy benefit manager affiliate, except as permitted by the federal Health Insurance Portability and Accountability Act (HIPAA) (P.L.104-191).
A violation of this subsection by a pharmacy benefit manager constitutes an unfair or deceptive act or practice in the business of insurance under IC 27-4-1-4.
As added by P.L.68-2020, SEC.1. Amended by P.L.32-2021, SEC.78; P.L.196-2021, SEC.22.