Michigan Laws 550.827 – Pharmacy benefit manager network; report; waiver; prohibition on spread pricing and fees for electronic processing
Current as of: 2023 | Check for updates
|
Other versions
Terms Used In Michigan Laws 550.827
- Claim: means a request for payment for administering, filling, or refilling a drug or for providing a pharmacy service or a medical supply or device to an enrollee. See Michigan Laws 550.815
- Contract: A legal written agreement that becomes binding when signed.
- Director: means the director of the department. See Michigan Laws 550.815
- Enrollee: means that term as defined in section 116 of the insurance code of 1956, 1956 PA 218, MCL 500. See Michigan Laws 550.815
- Health plan: means a qualified health plan as that term is defined in section 1261 of the insurance code of 1956, 1956 PA 218, MCL 500. See Michigan Laws 550.815
- Mail-order pharmacy: means a pharmacy whose primary business is to receive prescriptions by mail, fax, or through electronic submissions, dispense drugs to enrollees through the use of the United States Postal Service or other common carrier services, and provide consultation with patients electronically rather than face-to-face. See Michigan Laws 550.817
- Pharmacist: means that term as defined in section 17707 of the public health code, 1978 PA 368, MCL 333. See Michigan Laws 550.817
- Pharmacy: means that term as defined in section 17707 of the public health code, 1978 PA 368, MCL 333. See Michigan Laws 550.817
- pharmacy benefit manager: means an entity that contracts with a pharmacy or a pharmacy services administration organization on behalf of a health plan or carrier to provide pharmacy health services to individuals covered by the health plan or carrier or administration that includes, but is not limited to, any of the following:
(i) Contracting directly or indirectly with pharmacies to provide drugs to enrollees or other covered persons. See Michigan Laws 550.817Pharmacy benefit manager network: means a network of pharmacists or pharmacies that are offered by an agreement or contract to provide pharmacist services. See Michigan Laws 550.817 Plan sponsor: means that term as defined in section 7705 of the insurance code of 1956, 1956 PA 218, MCL 500. See Michigan Laws 550.817 Retail pharmacy: means a pharmacy that dispenses prescription drugs to the public at retail primarily to individuals that reside in close proximity to the pharmacy, typically by face-to-face interaction with the individual or the individual's caregiver. See Michigan Laws 550.819 Specialty pharmacy: means a pharmacy that dispenses specialty drugs to patients and that is nationally accredited by an independent third party. See Michigan Laws 550.819 Spread pricing: means the model of prescription drug pricing in which a pharmacy benefit manager charges a health plan a contracted price for prescription drugs, and the contracted price for the prescription drugs differs from the amount the pharmacy benefit manager directly or indirectly pays the pharmacist or pharmacy for pharmacist services. See Michigan Laws 550.819 state: when applied to the different parts of the United States, shall be construed to extend to and include the District of Columbia and the several territories belonging to the United States; and the words "United States" shall be construed to include the district and territories. See Michigan Laws 8.3o
(1) A pharmacy benefit manager shall provide a reasonably adequate and accessible retail pharmacy benefit manager network for the provision of drugs for a health plan that must provide for convenient enrollee access to pharmacies within a reasonable distance from an enrollee’s residence, as determined by the director. For purposes of this subsection, retail pharmacy benefit manager network does not include a mail-order pharmacy or specialty pharmacy.
(2) A pharmacy benefit manager shall submit to the director a retail pharmacy benefit manager network adequacy report that describes the retail pharmacy benefit manager network and the retail pharmacy benefit manager network’s accessibility in this state. The report must categorize the network by urban, suburban, and rural geography and must include the applicable zip codes.
(3) A pharmacy benefit manager may apply for a waiver from the director if the pharmacy benefit manager is unable to meet the network adequacy requirements under subsection (1).
(4) To apply for a waiver under subsection (3), a pharmacy benefit manager must submit to the director an application in a form and manner prescribed by the director that does both of the following:
(a) Demonstrates with specific data why the pharmacy benefit manager is not able to meet the network adequacy requirements under subsection (1).
(b) Includes information as to the steps that the pharmacy benefit manager has taken and will take to address network adequacy.
(5) If the director grants a waiver under subsection (3), the waiver expires after 2 years. If a pharmacy benefit manager seeks a renewal of the waiver, the director must consider the steps that the pharmacy benefit manager has taken over the 2-year period covered by the waiver to address network adequacy.
(6) A pharmacy benefit manager shall not conduct spread pricing in this state. However, if a contract between a plan sponsor and a health plan is in effect on the effective date of this act and the contract conflicts with this subsection, for that contract, this subsection applies to the pharmacy benefit manager beginning on the date the contract is amended, extended, or renewed, or before January 1, 2028, whichever is earlier.
(7) A pharmacy benefit manager shall not charge a pharmacy or pharmacist a fee to process a claim electronically.