Michigan Laws 550.839 – Retail pharmacies; contractual restrictions and limitations; use of untrue, deceptive, or misleading advertisements; reversal and resubmission of claims; termination of pharmacy from pharmacy benefit
Current as of: 2023 | Check for updates
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Terms Used In Michigan Laws 550.839
- Carrier: means that term as defined in section 3701 of the insurance code of 1956, 1956 PA 218, MCL 500. See Michigan Laws 550.815
- 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.
- Fraud: Intentional deception resulting in injury to another.
- 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
- Network pharmacy: means a retail pharmacy or other pharmacy that contracts directly or through a pharmacy services administration organization with a pharmacy benefit manager. See Michigan Laws 550.817
- Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
- 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 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 contract between a retail pharmacy and a pharmacy benefit manager or plan sponsor must not prohibit the retail pharmacy from offering either of the following as an ancillary service of the retail pharmacy:
(a) The delivery of a prescription drug by mail or common carrier to a patient or personal representative on request of the patient or personal representative if the request is made before the drug is delivered.
(b) The delivery of a prescription to a patient or personal representative by an employee or contractor of the retail pharmacy.
(2) Except as otherwise provided in a contract described in subsection (1), the retail pharmacy shall not charge a plan sponsor or pharmacy benefit manager for the delivery service described in subsection (1).
(3) If a retail pharmacy provides a delivery service described in subsection (1) to a patient, the retail pharmacy must disclose both of the following to the patient or personal representative:
(a) Any fee charged to the patient for the delivery of a prescription drug.
(b) The plan sponsor or pharmacy benefit manager may not reimburse the patient for the fee described in subdivision (a).
(4) Except as otherwise provided in a contract between a mail-order pharmacy or specialty pharmacy and a carrier, health plan, or pharmacy benefit manager, the carrier, health plan, or pharmacy benefit manager shall not require pharmacist or pharmacy accreditation standards or recertification requirements inconsistent with, more stringent than, or in addition to federal and state requirements to obtain reimbursement for a covered drug.
(5) A pharmacy benefit manager shall not cause or knowingly permit the use of any advertisement, promotion, solicitation, representation, proposal, or offer that is untrue, deceptive, or misleading.
(6) A pharmacy benefit manager shall not reverse and resubmit the claim of a network pharmacy:
(a) Without prior and proper notification to the network pharmacy.
(b) Without just cause or attempt to first reconcile the claim with the pharmacy.
(c) More than 90 days after the claim was first affirmatively adjudicated.
(7) The termination of a pharmacy from a pharmacy benefit manager network must not release the retail pharmacy benefit manager from the obligation to make any payment due to the pharmacy for an affirmatively adjudicated claim unless payments are withheld because of an investigation relating to insurance fraud.
(8) A carrier, health plan, or pharmacy benefit manager shall not retaliate against a pharmacist or pharmacy based on the pharmacist’s or pharmacy’s exercise of any right or remedy under this act. Retaliation prohibited by this subsection includes any of the following:
(a) Terminating or refusing to renew a contract with the pharmacist or pharmacy.
(b) Subjecting the pharmacist or pharmacy to increased audits.
(c) Failing to promptly pay the pharmacist or pharmacy any money owed by the pharmacy benefit manager to the pharmacist or pharmacy.
(9) This section does not prohibit the use of remote pharmacies, secure locker systems, or other types of pickup stations if such services are otherwise permitted by law.
(10) The provisions of this act may not be waived, voided, or nullified by contract.
(11) As used in this section, “personal representative” means an individual who has authority to act on behalf of another individual in making decisions related to health care as described in 45 C.F.R. § 164.502(g).