South Carolina Code 38-71-2230. Pharmacy benefits manager prohibited from taking certain actions
(A) A pharmacy benefits manager or representative of a pharmacy benefits manager shall not:
Terms Used In South Carolina Code 38-71-2230
- Claim: means a request from a pharmacy or pharmacist to be reimbursed for the cost of administering, filling, or refilling a prescription for a drug or for providing a medical supply or device. See South Carolina Code 38-71-2200
- Contract: A legal written agreement that becomes binding when signed.
- Health benefit plan: means any individual, blanket, or group plan, policy, or contract for health care services issued or delivered by a health care insurer in this State as defined in § 38-71-670(6) and 38-71-840(14), including the state health plan as defined in § 1-11-710. See South Carolina Code 38-71-2200
- 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 services: means products, goods, and services, or any combination of products, goods, and services, provided as a part of the practice of pharmacy. See South Carolina Code 38-71-2200
- Pharmacy benefits manager: means an entity that contracts with pharmacists or pharmacies on behalf of an insurer, third party administrator, or the South Carolina Public Employee Benefit Authority to:
(a) process claims for prescription drugs or medical supplies or provide retail network management for pharmacies or pharmacists;
(b) pay pharmacies or pharmacists for prescription drugs or medical supplies; or
(c) negotiate rebates with manufacturers for drugs paid for or procured as described in this article. See South Carolina Code 38-71-2200 - Pharmacy benefits manager affiliate: means a pharmacy or pharmacist that directly or indirectly, through one or more intermediaries, owns or controls, is owned or controlled by, or is under common ownership or control with a pharmacy benefits manager. See South Carolina Code 38-71-2200
(1) cause or knowingly permit the use of any advertisement, promotion, solicitation, representation, proposal, or offer that is untrue, deceptive, or misleading;
(2) charge a pharmacist or pharmacy a fee related to the adjudication of a claim other than a reasonable fee for the receipt and processing of a pharmacy claim;
(3) engage, with the express intent or purpose of driving out competition or financially injuring competitors, in a pattern or practice of reimbursing independent pharmacies or pharmacists in this State consistently less than the amount that the pharmacy benefits manager reimburses a pharmacy benefits manager affiliate for providing the same pharmacist services;
(4) collect or require a pharmacy or pharmacist to collect from an insured a copayment for a prescription drug at the point of sale in an amount that exceeds the lesser of:
(a) the contracted copayment amount;
(b) the amount an individual would pay for a prescription drug if that individual was paying cash; or
(c) the contracted amount for the drug.
(5) require the use of mail order for filling prescriptions unless required to do so by the health benefit plan or the health benefit plan design;
(6) charge a fee related to the adjudication of a claim without providing the cause for each adjustment or fee;
(7) penalize or retaliate against a pharmacist or pharmacy for exercising rights provided pursuant to the provisions of this chapter;
(8) prohibit a pharmacist or pharmacy from offering and providing direct and limited delivery services including incidental mailing services, to an insured as an ancillary service of the pharmacy; or
(9) any combination thereof.
(B) A claim for pharmacist services may not be retroactively denied or reduced after adjudication of the claim unless the:
(1) original claim was submitted fraudulently;
(2) original claim payment was incorrect because the pharmacy or pharmacist had already been paid for the pharmacist services;
(3) pharmacist services were not properly rendered by the pharmacy or pharmacist; or
(4) adjustment was agreed upon by the pharmacy prior to the denial or reduction.
(C) This subsection may not be construed to limit overpayment recovery efforts as set forth in § 38-59-250.
A pharmacy may not be subject to a charge-back or recoupment for a clerical or recordkeeping error in a required document or record, including a typographical or computer error, unless the error resulted in overpayment to the pharmacy.
(D) Termination of a pharmacy or pharmacist from a pharmacy benefits manager network does not release the pharmacy benefits manager from the obligation to make any payment due to the pharmacy or pharmacist for pharmacist services properly rendered according to the contract.
(E) A pharmacy benefits manager may maintain more than one network for different pharmacy services. Each individual network may require different pharmacy accreditation standards or certification requirements for participating in the network provided that the pharmacy accreditation standards or certification requirements are applied without regard to a pharmacy’s or pharmacist’s status as an independent pharmacy or pharmacy benefits manager affiliate. Each individual pharmacy location as identified by its National Council for Prescription Drug Program identification number may have access to more than one network so long as the pharmacy location meets the pharmacy accreditation standards or certification requirements of each network.
(F) Nothing in this article abridges the right of a pharmacist to refuse to fill or refill a prescription as referenced in § 40-43-86(E)(6) of the South Carolina Pharmacy Practice Act.
(G) Nothing in this article may be construed to require a pharmacy benefits manager to allow participation in a network that would not be required by § 38-71-147.