(a) (1) The Insurance Commissioner may review and approve the compensation program of a pharmacy benefits manager with a health benefit plan to ensure that the reimbursement for pharmacist services paid to a pharmacist or pharmacy is fair and reasonable to provide an adequate pharmacy benefits manager network for a health benefit plan under the standards issued by rule of the State Insurance Department.(2) All information and data acquired during the review under subdivision (a)(1) of this section is:(A) Considered proprietary and confidential under § 23-61-107(a)(4) and § 23-61-207; and(B) Not subject to the Freedom of Information Act of 1967, § 25-19-101 et seq.
(1) The Insurance Commissioner may review and approve the compensation program of a pharmacy benefits manager with a health benefit plan to ensure that the reimbursement for pharmacist services paid to a pharmacist or pharmacy is fair and reasonable to provide an adequate pharmacy benefits manager network for a health benefit plan under the standards issued by rule of the State Insurance Department.
(2) All information and data acquired during the review under subdivision (a)(1) of this section is:(A) Considered proprietary and confidential under § 23-61-107(a)(4) and § 23-61-207; and(B) Not subject to the Freedom of Information Act of 1967, § 25-19-101 et seq.
(A) Considered proprietary and confidential under § 23-61-107(a)(4) and § 23-61-207; and
(B) Not subject to the Freedom of Information Act of 1967, § 25-19-101 et seq.
(b) A pharmacy benefits manager or representative of a pharmacy benefits manager shall not:(1) Cause or knowingly permit the use of any advertisement, promotion, solicitation, representation, proposal, or offer that is untrue, deceptive, or misleading;(2) Unless reviewed and approved by the commissioner, charge a pharmacist or pharmacy a fee related to the adjudication of a claim, including without limitation a fee for:(A) The receipt and processing of a pharmacy claim;(B) The development or management of claims processing services in a pharmacy benefits manager network; or(C) Participation in a pharmacy benefits manager network;(3) Unless reviewed and approved by the commissioner in coordination with the Arkansas State Board of Pharmacy, require pharmacy accreditation standards or certification requirements inconsistent with, more stringent than, or in addition to requirements of the board;(4) (A) Reimburse a pharmacy or pharmacist in the state an amount less than the amount that the pharmacy benefits manager reimburses a pharmacy benefits manager affiliate for providing the same pharmacist services.(B) The amount shall be calculated on a per-unit basis using the same generic product identifier or generic code number;(5) (A) Pay or reimburse a pharmacy or pharmacist for the ingredient drug product component of pharmacist services less than the national average drug acquisition cost or, if the national average drug acquisition cost is unavailable, the wholesale acquisition cost.(B) (i) The Employee Benefits Division community pharmacy reimbursement model for pharmacist services in partnership with the University of Arkansas for Medical Sciences-based prescription drug program satisfies the intent of this subdivision (b)(5).(ii) A plan using the model described in subdivision (b)(5)(B)(i) of this section is exempt from complying with subdivision (b)(5)(A) of this section if the reimbursement model is maintained as determined by the commissioner.(iii) If a plan deviates from this reimbursement model, the plan shall be subject to subdivision (b)(5)(A) of this section;(6) Make or permit any reduction of payment for pharmacist services by a pharmacy benefits manager or a healthcare payor directly or indirectly to a pharmacy under a reconciliation process to an effective rate of reimbursement, including without limitation generic effective rates, brand effective rates, direct and indirect remuneration fees, or any other reduction or aggregate reduction of payment;(7) (A) Prohibit a pharmacist from dispensing HIV pre-exposure prophylaxis or HIV post-exposure prophylaxis under a statewide protocol.(B) As used in subdivision (b)(7)(A) of this section, “HIV” means the human immunodeficiency virus or any other identified causative agent of acquired immunodeficiency syndrome, commonly known as “AIDS”;(8) Do any combination of the actions listed in subdivisions (b)(1)-(7) of this section; or (9) Unless reviewed and approved by the commissioner in coordination with the board, require pharmacy accreditation standards or certification requirements inconsistent with, more stringent than, or in addition to requirements of the board.
(1) Cause or knowingly permit the use of any advertisement, promotion, solicitation, representation, proposal, or offer that is untrue, deceptive, or misleading;
(2) Unless reviewed and approved by the commissioner, charge a pharmacist or pharmacy a fee related to the adjudication of a claim, including without limitation a fee for:(A) The receipt and processing of a pharmacy claim;(B) The development or management of claims processing services in a pharmacy benefits manager network; or(C) Participation in a pharmacy benefits manager network;
(A) The receipt and processing of a pharmacy claim;
(B) The development or management of claims processing services in a pharmacy benefits manager network; or
(C) Participation in a pharmacy benefits manager network;
(3) Unless reviewed and approved by the commissioner in coordination with the Arkansas State Board of Pharmacy, require pharmacy accreditation standards or certification requirements inconsistent with, more stringent than, or in addition to requirements of the board;
(4) (A) Reimburse a pharmacy or pharmacist in the state an amount less than the amount that the pharmacy benefits manager reimburses a pharmacy benefits manager affiliate for providing the same pharmacist services.(B) The amount shall be calculated on a per-unit basis using the same generic product identifier or generic code number;
(A) Reimburse a pharmacy or pharmacist in the state an amount less than the amount that the pharmacy benefits manager reimburses a pharmacy benefits manager affiliate for providing the same pharmacist services.
(B) The amount shall be calculated on a per-unit basis using the same generic product identifier or generic code number;
(5) (A) Pay or reimburse a pharmacy or pharmacist for the ingredient drug product component of pharmacist services less than the national average drug acquisition cost or, if the national average drug acquisition cost is unavailable, the wholesale acquisition cost.(B) (i) The Employee Benefits Division community pharmacy reimbursement model for pharmacist services in partnership with the University of Arkansas for Medical Sciences-based prescription drug program satisfies the intent of this subdivision (b)(5).(ii) A plan using the model described in subdivision (b)(5)(B)(i) of this section is exempt from complying with subdivision (b)(5)(A) of this section if the reimbursement model is maintained as determined by the commissioner.(iii) If a plan deviates from this reimbursement model, the plan shall be subject to subdivision (b)(5)(A) of this section;
(A) Pay or reimburse a pharmacy or pharmacist for the ingredient drug product component of pharmacist services less than the national average drug acquisition cost or, if the national average drug acquisition cost is unavailable, the wholesale acquisition cost.
(B) (i) The Employee Benefits Division community pharmacy reimbursement model for pharmacist services in partnership with the University of Arkansas for Medical Sciences-based prescription drug program satisfies the intent of this subdivision (b)(5).(ii) A plan using the model described in subdivision (b)(5)(B)(i) of this section is exempt from complying with subdivision (b)(5)(A) of this section if the reimbursement model is maintained as determined by the commissioner.(iii) If a plan deviates from this reimbursement model, the plan shall be subject to subdivision (b)(5)(A) of this section;
(i) The Employee Benefits Division community pharmacy reimbursement model for pharmacist services in partnership with the University of Arkansas for Medical Sciences-based prescription drug program satisfies the intent of this subdivision (b)(5).
(ii) A plan using the model described in subdivision (b)(5)(B)(i) of this section is exempt from complying with subdivision (b)(5)(A) of this section if the reimbursement model is maintained as determined by the commissioner.
(iii) If a plan deviates from this reimbursement model, the plan shall be subject to subdivision (b)(5)(A) of this section;
(6) Make or permit any reduction of payment for pharmacist services by a pharmacy benefits manager or a healthcare payor directly or indirectly to a pharmacy under a reconciliation process to an effective rate of reimbursement, including without limitation generic effective rates, brand effective rates, direct and indirect remuneration fees, or any other reduction or aggregate reduction of payment;
(7) (A) Prohibit a pharmacist from dispensing HIV pre-exposure prophylaxis or HIV post-exposure prophylaxis under a statewide protocol.(B) As used in subdivision (b)(7)(A) of this section, “HIV” means the human immunodeficiency virus or any other identified causative agent of acquired immunodeficiency syndrome, commonly known as “AIDS”;
(A) Prohibit a pharmacist from dispensing HIV pre-exposure prophylaxis or HIV post-exposure prophylaxis under a statewide protocol.
(B) As used in subdivision (b)(7)(A) of this section, “HIV” means the human immunodeficiency virus or any other identified causative agent of acquired immunodeficiency syndrome, commonly known as “AIDS”;
(8) Do any combination of the actions listed in subdivisions (b)(1)-(7) of this section; or
(9) Unless reviewed and approved by the commissioner in coordination with the board, require pharmacy accreditation standards or certification requirements inconsistent with, more stringent than, or in addition to requirements of the board.
(c) A claim or aggregate of claims for pharmacist services shall not be directly or indirectly retroactively denied or reduced after adjudication of the claim or aggregate of claims unless:(1) The original claim was submitted fraudulently;(2) The original claim payment was incorrect because the pharmacy or pharmacist had already been paid for the pharmacist services; or(3) The pharmacist services were not properly rendered by the pharmacy or pharmacist.
(1) The original claim was submitted fraudulently;
(2) The original claim payment was incorrect because the pharmacy or pharmacist had already been paid for the pharmacist services; or
(3) The pharmacist services were not properly rendered by the pharmacy or pharmacist.
(d) Termination of a pharmacy or pharmacist from a pharmacy benefits manager network shall not release the pharmacy benefits manager from the obligation to make any payment due to the pharmacy or pharmacist for pharmacist services properly rendered.
(e) The commissioner may issue a rule establishing prohibited practices of pharmacy benefits managers providing claims processing services or other prescription drug or device services for health benefit plans.
(f) Upon request, a pharmacy benefits manager, including pharmacy benefits managers contracting for Medicare pharmacy and pharmacist benefits, shall provide a pharmacy services administrative organization, pharmacy, or pharmacist with each pharmacy claims bank identification number, pharmacy claims group number, pharmacy claims processor control number, and each unique combination for pharmacy claims for each pharmacy network established or administered by a pharmacy benefits manager to enable the pharmacy services administrative organization, pharmacy, or pharmacist to make an informed healthcare contracting decision to support negotiating a new contract or to exit or renew an existing contract.
(g) For a new contract, an opt-out contract, a contract amendment, or a renewal of an existing network, a pharmacy benefits manager, including pharmacy benefits managers contracting for Medicare pharmacy and pharmacist benefits, shall clearly list for the pharmacy services administrative organization, a pharmacy, or pharmacist each pharmacy claims bank identification number, pharmacy claims group number, pharmacy claims processor control number, and each unique combination for pharmacy claims for each pharmacy network established or administered by a pharmacy benefits manager to enable the pharmacy services administrative organization, pharmacy, or pharmacist to make an informed healthcare contracting decision.
(h) (1) An opt-out contract shall include at least sixty-days' notice to the pharmacy services administrative organization, pharmacy, or pharmacist.(2) The notice required under subdivision (h)(1) of this section shall be sent by both email and fax.(3) The opt-out option in an opt-out contract shall offer the pharmacy services administrative organization, pharmacy, or pharmacist the ability to notify the pharmacy benefits manager of the decision to opt-out or remain in the network.(4) If a pharmacy benefits manager has not received a reply from the pharmacy services administrative organization, pharmacy, or pharmacist within thirty (30) days of the first notice that the opt-out notice was received, the pharmacy benefits manager shall send a notice to the pharmacy services administrative organization, pharmacy, or pharmacist a notification by certified mail of the opt-out contract.
(1) An opt-out contract shall include at least sixty-days' notice to the pharmacy services administrative organization, pharmacy, or pharmacist.
(2) The notice required under subdivision (h)(1) of this section shall be sent by both email and fax.
(3) The opt-out option in an opt-out contract shall offer the pharmacy services administrative organization, pharmacy, or pharmacist the ability to notify the pharmacy benefits manager of the decision to opt-out or remain in the network.
(4) If a pharmacy benefits manager has not received a reply from the pharmacy services administrative organization, pharmacy, or pharmacist within thirty (30) days of the first notice that the opt-out notice was received, the pharmacy benefits manager shall send a notice to the pharmacy services administrative organization, pharmacy, or pharmacist a notification by certified mail of the opt-out contract.
(i) (1) A pharmacy benefits manager shall not offer “take it or leave it” terms and conditions in a contract that would violate requirements of state law.(2) A pharmacy benefits manager shall actively respond, communicate, and adjust to the concerns of a pharmacy services administrative organization, pharmacy, or pharmacist that proposed or existing contract and provider manual terms do not follow state law.
(1) A pharmacy benefits manager shall not offer “take it or leave it” terms and conditions in a contract that would violate requirements of state law.
(2) A pharmacy benefits manager shall actively respond, communicate, and adjust to the concerns of a pharmacy services administrative organization, pharmacy, or pharmacist that proposed or existing contract and provider manual terms do not follow state law.
(j) A pharmacy benefits manager shall not utilize a pharmacy benefits manager national contract to pharmacies that does not include a separate Arkansas-based amendment or Arkansas-specific contract that clearly complies with this subchapter and other state laws.