Utah Code 31A-46-304. Claims practices
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(1) A pharmacy benefit manager shall permit a pharmacy to collect the amount of a customer’s cost share from any source.
Terms Used In Utah Code 31A-46-304
- Contract: A legal written agreement that becomes binding when signed.
- Cost share: means the amount paid by an insured customer under the customer's health benefit plan. See Utah Code 31A-46-102
- Drug: means the same as that term is defined in Section 58-17b-102. See Utah Code 31A-46-102
- Form: means one of the following prepared for general use:(74)(a)(i) a policy;(74)(a)(ii) a certificate;(74)(a)(iii) an application;(74)(a)(iv) an outline of coverage; or(74)(a)(v) an endorsement. See Utah Code 31A-1-301
- Fraud: Intentional deception resulting in injury to another.
- Pharmacist: means the same as that term is defined in Section 58-17b-102. See Utah Code 31A-46-102
- Pharmacy: means the same as that term is defined in Section 58-17b-102. See Utah Code 31A-46-102
- Pharmacy benefit manager: means a person licensed under this chapter to provide a pharmacy benefits management service. See Utah Code 31A-46-102
- Pharmacy service: means a product, good, or service provided to an individual by a pharmacy or pharmacist. See Utah Code 31A-46-102
(2) A pharmacy benefit manager may not deny or reduce a reimbursement to a pharmacy or a pharmacist after the adjudication of the claim, unless:(2)(a) the pharmacy or pharmacist submitted the original claim fraudulently;(2)(b) the original reimbursement was incorrect because:(2)(b)(i) the pharmacy or pharmacist had already been paid for the pharmacy service; or(2)(b)(ii) an unintentional error resulted in an incorrect reimbursement; or(2)(c) the pharmacy service was not rendered by the pharmacy or pharmacist.(3) Subsection (2) does not apply if:(3)(a) any form of an investigation or audit of pharmacy records for fraud, waste, abuse, or other intentional misrepresentation indicates that the pharmacy or pharmacist engaged in criminal wrongdoing, fraud, or other intentional misrepresentation; or(3)(b) the reimbursement is reduced as the result of the reconciliation of a reimbursement amount under a performance contract if:(3)(b)(i) the performance contract lays out clear performance standards under which the reimbursement for a specific drug may be increased or decreased; and(3)(b)(ii) the agreement between the pharmacy benefit manager and the pharmacy or pharmacist explicitly states, in a separate document that is signed by the pharmacy benefit manager and the pharmacy or pharmacist, that the provisions of Subsection (2) do not apply.