1. The following provisions shall apply if a pharmacy benefits manager requests the dispensing of a substitute prescription drug for a drug prescribed for a covered person:

 a. The pharmacy benefits manager may request the substitution of a lower priced generic and therapeutically equivalent prescription drug for a higher priced prescription drug.
 b. If the substitute prescription drug’s net cost to the covered person or to the health carrier exceeds the cost of the prescription drug originally prescribed for the covered person, the substitution shall be made only for medical reasons that benefit the covered person.

Terms Used In Iowa Code 510B.6

  • Covered person: means a policyholder, subscriber, or other person participating in a health benefit plan that has a prescription drug benefit managed by a pharmacy benefits manager. See Iowa Code 510B.1
  • following: when used by way of reference to a chapter or other part of a statute mean the next preceding or next following chapter or other part. See Iowa Code 4.1
  • Health care professional: means a physician or other health care practitioner licensed, accredited, registered, or certified to perform specified health care services consistent with state law. See Iowa Code 510B.1
  • Health carrier: means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, including an insurance company offering sickness and accident plans, a health maintenance organization, a nonprofit health service corporation, or a plan established pursuant to chapter 509A for public employees. See Iowa Code 510B.1
  • person: means individual, corporation, limited liability company, government or governmental subdivision or agency, business trust, estate, trust, partnership or association, or any other legal entity. See Iowa Code 4.1
  • Pharmacy: means the same as defined in section 155A. See Iowa Code 510B.1
  • Pharmacy benefits manager: means a person who, pursuant to a contract or other relationship with a third-party payor, either directly or through an intermediary, manages a prescription drug benefit provided by the third-party payor. See Iowa Code 510B.1
  • Prescription drug: means the same as defined in section 155A. See Iowa Code 510B.1
  • Prescription drug order: means the same as defined in section 155A. See Iowa Code 510B.1
 2. A pharmacy benefits manager shall obtain the approval of the prescribing health care professional prior to requesting any substitution under this section.
 3. A pharmacy benefits manager shall not substitute an equivalent prescription drug contrary to a prescription drug order that prohibits a substitution.
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