South Carolina Code 38-71-2245. Insured’s selection of in-network pharmacy; participation of pharmacy or pharmacist in a network; role of pharmacy benefits manager
(A)(1) A pharmacy benefits manager may neither limit an insured from selecting an in-network pharmacy or pharmacist of the insured’s choice nor deny the right of a pharmacy or pharmacist to participate in a network if the pharmacy or pharmacist meets the requirements for network participation set forth by the pharmacy benefits manager, and the pharmacy or pharmacist agrees to the contract terms, conditions, and rates of reimbursements.
Terms Used In South Carolina Code 38-71-2245
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Contract: A legal written agreement that becomes binding when signed.
- Department: means the Department of Insurance of South Carolina. See South Carolina Code 38-1-20
- insurance: includes annuities. See South Carolina Code 38-1-20
- 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 v2
(2) A pharmacy benefits manager may not impose any pharmacy accreditation standards or recertification requirements for network participation that unreasonably exceed state or federal requirements for licensure as a pharmacy in this State unless authorized under this chapter.
(B) Notwithstanding subsection (A), a pharmacy benefits manager may for specialized delivery drugs specify requirements for network participation that:
(1) directly relate to the ability of the pharmacy or pharmacist to store, handle, or deliver a prescription drug in a manner that ensures the quality, integrity, or safety of the drug, its delivery, or its use; or
(2) relate to quality metrics that affect a pharmacy’s or pharmacist’s ability to participate, provided that the pharmacy benefits manager applies such terms equally to all network participants.
(C) For prescription drugs that qualify as a high-cost prescription drug, subsection (A) of this section does not apply to a pharmacy benefits manager. A high-cost prescription drug is defined as a prescription drug whose current or prior year’s annual average wholesale price exceeded 300 percent of the Federal Poverty Level for a single-member household.
(D) A pharmacy benefits manager must provide notification of any changes to all applicable specialized delivery drug lists and high-cost prescription drug lists and must make such lists available on a website and upon request to participating pharmacies. A pharmacy may appeal a classification determination to the Department of Insurance.
(E) The provisions of this section do not apply to the coverage provided to employees, retirees, and their eligible dependents pursuant to § 1-11-710 by the South Carolina Public Employee Benefit Authority or through its contracted pharmacy benefits manager.