Title 27 — Title 27

Provider. No health insurance policy or employee benefit plan which is delivered, renewed, issued for delivery, or otherwise contracted for in this state shall: (1) Prevent any person who is a party to or beneficiary of any such health insurance policy or employee benefit plan fr…

Any provision in a health insurance policy or employee benefit plan which is delivered, renewed, issued for delivery, or otherwise contracted for in this state which is contrary to this article shall to the extent of such conflict be void. History: (Acts 1988, No. 88-379, p. 565,…

The provisions of this article do not mandate that any type of benefits for pharmaceutical services, including without limitation, prescription drugs, be provided by a health insurance policy or an employee benefit plan. History: (Acts 1988, No. 88-379, p. 565, §5.)

It shall be unlawful for any insurer or any person to provide any health insurance policy or employee benefit plan providing for pharmaceutical services, including without limitation, prescription drugs, that does not conform to the provisions of this article. History: (Acts 1988…

The Commissioner of Insurance shall not approve for sale in this state any health insurance policy or employee benefit plan providing for pharmaceutical services, including without limitation, prescription drugs, which does not conform to the provisions of this article or to the …

It shall be the duty and responsibility of the Commissioner of Insurance to enforce the provisions of this article. History: (Acts 1988, No. 88-379, p. 565, §8.)

Each willful violation of the provisions of this article shall be punishable as provided in Section 27-1-12. History: (Acts 1988, No. 88-379, p. 565, §9.)

This chapter shall be known as and may be cited as the Alabama Pharmacy Benefits Manager Licensure and Regulation Act. History: (Act 2019-457, §1.)

Pharmacies or Pharmacists. With respect to a pharmacist or pharmacy, a pharmacy benefits manager, directly or through an affiliate or a contracted third party, may not do any of the following: (1) Reimburse an in-network pharmacy or pharmacist in the state an amount less than the…

A pharmacy benefits manager may not knowingly make a material misrepresentation to a covered individual, pharmacist, or pharmacy. History: (Act 2021-341, §2.)

A pharmacist or pharmacy that participates in a health benefit plan’s pharmacy network shall process a prescription drug using the pharmacy benefits of the covered individual if failure to do so will result in a higher out-of-pocket cost to the covered individual. History: (Act 2…

Independent Pharmacies; Exceptions. (a) Notwithstanding any other provision of this chapter or any form of a contract to the contrary, with respect to an independent pharmacy, a pharmacy benefits manager, directly or through an affiliate or a contracted third party, may not do an…

Manufacturers. A pharmacy benefits manager, either directly or through a PBM affiliate, when performing pharmacy benefits management services or other prescription drug or device services for a health benefit plan client, shall pass on 100 percent of all rebates received, directl…

(a) This chapter establishes the standards and criteria for the regulation and licensure of pharmacy benefits managers providing claims processing services or other prescription drug or device services for health benefit plans. (b) The purpose of this chapter is to: (1) Promote, …

For purposes of this chapter, the following words have the following meanings: (1) AFFILIATE or PBM AFFILIATE. An entity, including, but not limited to, a pharmacy, health insurer, or group purchasing organization that directly or indirectly, through one or more intermediaries, h…

(a) A person may not establish or operate as a pharmacy benefits manager in this state without first obtaining a license from the commissioner. (b) Effective through December 31, 2021, to initially obtain a license or renew a license, a pharmacy benefits manager shall submit all …

(a) It shall be the responsibility of the commissioner to enforce this chapter and any conduct arising from any action taken by a pharmacy benefits manager or PBM affiliate pursuant to an audit conducted under Article 8, Chapter 23, Title 34, which violates this chapter. (b) The …

Nothing in this chapter is intended or shall be construed to do any of the following: (1) Be in conflict with existing relevant federal law. (2) Apply to any specialty drug. (3) Impact the ability of a hospital to mandate its employees’ use of a hospital- owned pharmacy. History:…

Reserved.

Individuals; Exceptions. (a) A pharmacy benefits manager may not do any of the following: (1) Require a covered individual, as a condition of payment or reimbursement, to purchase pharmacist services, including, but not limited to, prescription drugs, exclusively through a mail-o…

(a) For purposes of this section, client means a health insurer, payor, or health benefit plan. (b) If requested by a client under subsection (d), a pharmacy benefits manager shall prepare an annual report by June 1 which discloses all of the following with respect to that client…

Notwithstanding any other provision of law, when any contract or plan of health insurance, or any plan or agreement for health care services provides for the reimbursement or payment for services which are within the scope of practice of registered nurses who have passed or who a…

Nothing in this chapter shall prohibit a licensed hospital from prescribing in its bylaws, policies, rules, or regulations, the qualifications, training, experience, scope of permissible activities, and level or degree of supervision required of any certified registered nurse ane…

For the purposes of this chapter, certified registered nurse anesthetist means any licensed registered nurse licensed under Section 34-21-20, who is a graduate of a formal education program accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs or its…

For purposes of this chapter, “qualified long-term care services” includes care for necessary diagnostic, preventive, therapeutic, and rehabilitative services and maintenance, assisted living, or personal care services which are required by a chronically ill individual in a quali…

Treatment of Contract; Coverage. (a) The premiums paid for a long-term care insurance contract are deductible pursuant to Section 40-18-15, if the contract meets the following requirements: (1) Offers coverage only for qualified long-term care services and benefits incidental to …

Education Trust Fund. Any amounts of premium tax for long-term care coverage shall be deposited into the Education Trust Fund. History: (Acts 1995, No. 95-738, p. 772, §3.)

As used in this chapter, the following terms shall have the following meanings: (1) HEALTH BENEFIT PLAN. A health insurance policy that covers hospital, medical, or surgical expenses, health maintenance organizations, preferred provider organizations, medical service organization…

Born Child. (a) Every health benefit plan that provides maternity coverage shall provide coverage for the following: (1) All medically necessary inpatient care for a mother and her newly born child as determined by the woman’s prenatal care physician, obstetrician-gynecologist, c…

Capitation Payment, or Other Penalty for Health Care Provider in Compliance with Chapter; Prohibition Against Financial Encouragement of Early Discharge from Postpartum Care. No health benefit plan subject to the provisions of this chapter shall terminate the services, reduce cap…

of Insurance Company or Health Maintenance Organization License. A license issued by the Department of Insurance to an insurance company or a health maintenance organization shall be subject to suspension, revocation, or imposition or other administrative penalty authorized by la…

This chapter shall apply to all programs administered by the Alabama Medicaid Agency. History: (Acts 1996, No. 96-578, p. 915, §5.)

This chapter shall be known and may be cited as the “Women’s Access to Health Care Act.” History: (Acts 1996, No. 96-671, p. 1135, §1.)

The Legislature finds that the specialty of obstetrics and gynecology is devoted to primary and preventive health care of women throughout their lifetime. Significant numbers of women view their obstetrician and gynecologist as their primary or only physician. For many women, an …

As used in this chapter, the following terms shall have the following meanings: (1) HEALTH BENEFIT PLAN. Any individual or group plan, policy, or contract for health care services issued, delivered, issued for delivery, renewed in this state by a health care insurer, health maint…

Access to Obstetrician and Gynecologist Not Used as Primary Care Physicians. (a) Each health benefit plan which is issued, delivered, issued for delivery, or renewed in this state on or after October 1, 1996, shall allow obstetricians and gynecologists as primary care physicians.…

Any violation of this chapter shall constitute grounds for suspension or revocation of a license by the Department of Insurance issued to an insurance company or health maintenance organization. History: (Acts 1996, No. 96-671, p. 1135, §5.)

This chapter shall be known as “The Breast Cancer Screening Act.” History: (Acts 1997, No. 97-414, p. 685, §1.)

It is the intent of the Legislature to assist women with the early detection of breast cancer and thereby prevent the following: (1) Avoidable early death from breast cancer. (2) Avoidable suffering and impaired quality of life from late detection of breast cancer. (3) Avoidable …

As used in this chapter, the term “health benefit plan” has the following meaning: A health insurance policy, including a self-insured health plan, that covers hospital, medical, or surgical expenses, health maintenance organizations, preferred provider organizations, medical ser…

Every health benefit plan which provides coverage for surgical services for a mastectomy shall provide coverage for screening mammography as follows: (1) For women ages 40 to 49, inclusive, a mammogram at least every two years or more frequently based on the recommendation of a w…

(a) No health benefit plan subject to the provisions of this chapter shall terminate the services, reduce capitation payment, or otherwise penalize an attending physician or other health care provider who orders medical care consistent with this chapter. (b) Nothing in this chapt…

A license issued by the Department of Insurance to an insurance company or a health maintenance organization shall be subject to suspension, revocation, or imposition or other administrative penalty authorized by law, within the discretion of the Commissioner of Insurance, for an…

This chapter shall apply to all programs administered by the Alabama Medicaid Agency. History: (Acts 1997, No. 97-414, p. 685, §7.)

(a) For purposes of this section, the following terms have the following meanings: (1) COST-SHARING REQUIREMENT. A deductible, copayment, coinsurance, or similar expense borne by the insured for a covered benefit under a health benefit plan. (2) DIAGNOSTIC BREAST EXAMINATION. A m…

(a) An insurance policy or contract providing for third-party payment or prepayment of health or medical expenses shall include a provision for the payment to a supervising physician for necessary medical or surgical services that are provided by a licensed physician assistant pr…

(a) There is hereby created the Alabama Health Insurance Plan which shall, as a high risk pool in the State of Alabama, provide health insurance coverage to eligible individuals as an alternative to requiring insurers to offer guaranteed-issue policies, as provided in the Health …

The plan shall have the general powers and authority granted under the laws of this state to health insurers and in addition thereto, the specific authority to do all of the following: (1) Enter into contracts as are necessary or proper to carry out the provisions and purposes of…

There is hereby created the Alabama Small Employer Allocation Program which shall promote the availability of health insurance coverage to small employers regardless of their health status or claims experience, to prevent abusive rating practices, to prevent segmentation of the h…

“Small Employer” Defined. (a) The Commissioner of Insurance shall, by regulation, establish the conditions, restrictions, requirements, and plan of operation of the Alabama Small Employer Allocation Program consistent with the requirements of the Health Insurance Portability and …