Title 58 — INSURANCE

The written agreement shall include a statement of duties which the administrator is expected to perform on behalf of the insurer and the lines, classes, or types of insurance for which the administrator is to be authorized to administer. The agreement shall make provision with r…

The insurer or administrator may, with written notice, terminate the written agreement for cause as provided in the agreement. The insurer may suspend the underwriting authority of the administrator during the pendency of any dispute regarding the cause for termination of the wri…

If an insurer utilizes the services of an administrator, the payment to the administrator of any premiums or charges for insurance by or on behalf of the insured party shall be deemed to have been received by the insurer, and the payment of return premiums or claim payments forwa…

Every administrator shall maintain and make available to the insurer complete books and records of all transactions performed on behalf of the insurer. The books and records shall be maintained in accordance with prudent standards of insurance record keeping and must be maintaine…

The director shall have access to books and records maintained by an administrator for the purposes of examination, audit, and inspection. Any trade secrets contained in such books and records, including the identity and addresses of policyholders and certificate holders, shall b…

Terms used in this chapter mean: (1) "Brand name," the same as set forth in § 36-11-2 ; (2) "Covered individual," a member, participant, enrollee, contract holder, policy holder, or beneficiary of a third-party payor who is provided health coverage by the third-party payor. The t…

A third-party payor, 340B entity, or a pharmacy, may bring a civil action to enforce this chapter, including injunctive relief, and seek civil damages for a violation of this chapter. Source: SL 2004, ch 311 , § 10; SL 2023, ch 166 , § 11; SL 2024, ch 203 , § 3, eff. Jan. 1, 2025…

Source: SL 2004, ch 311 , § 11; SL 2023, ch 166 , § 20.

A pharmacy benefit manager may not contractually require a pharmacy that is a participating provider in a health benefit plan provided by a third-party payor, from charging a covered individual or collecting from a covered individual a cost share for a prescription drug or pharma…

A pharmacy benefit manager may not, directly or indirectly, retroactively adjust a claim for reimbursement submitted by a pharmacy for a prescription drug, unless: (1) The adjustment is necessitated by a pharmacy audit conducted in accordance with chapter 58-29F ; (2) The adjustm…

Nothing in §§ 58-29E-12 to 58-29E-15 , inclusive, shall prohibit a pharmacy benefit manager from adjusting claim payment for the benefit of a covered individual if there was an error in the adjudication of a claim submitted by or on behalf of the covered individual. Source: SL 20…

A pharmacy benefit manager or a pharmacy benefit manager affiliate who has engaged in a discriminatory act, as prohibited in § 58-29E-15 , is liable to the 340B entity for damages, including actual and consequential damages, and is liable for reasonable attorneys' fees and costs.…

A pharmacy benefit manager may not assess, charge, or collect, from a pharmacy or pharmacist, any remuneration or fee, including: (1) An accreditation fee; (2) A brand effective rate fee; (3) A claim processing fee; (4) A credentialing fee; (5) A dispensing fee; (6) An effective …

Prior to placing a prescription drug on a maximum allowable cost list, a pharmacy benefit manager shall ensure that the prescription drug is: (1) Listed as therapeutically and pharmaceutically equivalent in the latest edition of, or any supplement to, the Food and Drug Administra…

A pharmacy benefit manager shall: (1) Provide each pharmacy in a pharmacy network with reasonable access to each maximum allowable cost list to which the pharmacy is subject; (2) Update a maximum allowable cost list, within seven calendar days from the date of any increase, at or…

A pharmacy benefit manager may not reimburse any pharmacy located in this state an amount that is less than that which the pharmacy benefit manager reimburses a pharmacy benefit manager affiliate for dispensing the same prescription drug as that dispensed by the pharmacy. The rei…

A person may not act as a pharmacy benefit manager in this state without a license to operate as a third party administrator pursuant to chapter 58-29D . Sections 58-29D -26, 58-29D -27, and 58-29D -29 do not apply to pharmacy benefits managers. Source: SL 2004, ch 311 , § 2; SL …

A pharmacy benefit manager licensed under this chapter shall, at the request of the Division of Insurance, provide: (1) The amount charged or claimed by the pharmacy benefit manager, in a format that allows the division to identify all instances of spread pricing; and (2) Informa…

In addition to any grounds set forth in § 58-29D-31 , the director may deny a pharmacy benefit manager's application for an initial or a renewed license, and may suspend or revoke a pharmacy benefit manager's license, if the director determines that the pharmacy benefit manager, …

Each pharmacy benefit manager shall perform its duties in good faith and with fair dealing toward the third-party payor. Source: SL 2004, ch 311 , § 3; SL 2023, ch 166 , § 3.

A third-party payor may request that a pharmacy benefit manager, with which it has a pharmacy benefit management services contract, disclose to the third-party payor the amount of all rebate revenues and the nature, type, and amounts of all other revenues that the pharmacy benefi…

A pharmacy benefit manager, unless authorized pursuant to the terms of its contract with a third-party payor, may not contact any covered individual, without the express written permission of the third-party payor. Source: SL 2004, ch 311 , § 5; SL 2023, ch 166 , § 5.

Except for utilization information, a third-party payor shall maintain information disclosed in response to a request under § 58-29E-4 as confidential and proprietary information, and may not use that information for any other purpose or disclose that information to any other per…

A third-party payor that has contracted with a licensed pharmacy benefit manager may audit the pharmacy benefit manager once each calendar year. The audit authorized by this section is in addition to any other statutory or contractual audit rights. As part of the audit, a third-p…

Except as provided in chapter 58-17K , and in accordance with the audit provisions in § 58-29E-7 , a third-party payor that has contracted with a licensed pharmacy benefit manager may not publish, or directly or indirectly disclose: (1) Any information that reveals the identity o…

A pharmacy benefit manager may request that a lower - priced generic and therapeutically equivalent prescription drug be dispensed to a covered individual, as a substitute for a higher - priced prescription drug. If the substitute prescription drug's net cost is higher for the co…

A pharmacy benefit manager may neither prohibit a pharmacist or pharmacy from, nor penalize a pharmacist or pharmacy for, informing a covered individual about: (1) The cost of a prescription drug; (2) The amount of reimbursement that the pharmacy will receive for dispensing the p…

The Division of Insurance shall promulgate rules, pursuant to chapter 1-26 , to carry out the issuance of the license required by § 58-29E-2 and the enforcement provisions of this chapter. The rules may include the following: (1) Definition of terms; (2) Use of prescribed forms; …

The pharmacy audit integrity program is hereby established to provide standards for an audit of pharmacy records carried out by a pharmacy benefits manager or any entity that represents the pharmacy benefits manager. Source: SL 2013, ch 254 , § 1.

If contractually required, an auditing entity shall provide a copy of the claims included in the audit to the plan sponsor, and any recouped money shall be returned to the plan sponsor. Source: SL 2013, ch 254 , § 10.

The provisions of this chapter do not apply to any investigative audit that involves fraud, willful misrepresentation, or on any audit completed by the State of South Dakota on health care programs operated by the state. Source: SL 2013, ch 254 , § 11.

In addition to the remedies otherwise provided for in this chapter, in chapter 58-29E , or under general South Dakota law, any pharmacy subject to an audit procedure may bring a civil action to enforce the provisions of this chapter and to seek damages from the pharmacy benefits …

Term used in this chapter mean: (1) "Entity," a pharmacy benefits manager or any person or organization that represents these companies, groups, or organizations in any capacity; (2) "Plan sponsor," the employer in the case of an employee benefit plan established or maintained by…

The pharmacy benefits manager shall disclose an amendment to the pharmacy audit terms in a contract between a pharmacy and a pharmacy benefits manager to the pharmacy at least sixty days prior to the effective date of the proposed change. Source: SL 2013, ch 254 , § 3.

Unless otherwise prohibited by federal statutes or regulations, any entity conducting a pharmacy audit shall: (1) Give a pharmacy a minimum fourteen days written notice before conducting initial on-site audit; (2) Conduct an audit that involves clinical or professional judgment i…

Unless otherwise prohibited by federal statutes or regulations, for any entity conducting a pharmacy audit the following audit items apply: (1) The period covered by the audit may not exceed twenty-four months from the date that the claim was submitted to or adjudicated by the en…

For recoupment or chargeback, the following criteria apply: (1) Audit parameters shall consider consumer-oriented parameters based on manufacturer listings; (2) A pharmacy's usual and customary price for compounded medications is considered the reimbursable cost unless the pricin…

To validate the pharmacy record and delivery, the pharmacy may use authentic and verifiable statements or records including medication administration records of a nursing home, assisted living facility, hospital, physician, or other authorized practitioner or additional audit doc…

A preliminary audit report shall be delivered to the pharmacy within sixty days after the conclusion of the audit. A pharmacy shall be allowed at least forty-five days following receipt of the preliminary audit, to provide documentation to address any discrepancy found in the aud…

The entity conducting the audit shall establish a written appeals process which shall include appeals of preliminary reports and final reports. Source: SL 2013, ch 254 , § 9.

Terms used in this chapter mean: (1) "Pharmaceutical manufacturer," any person engaged in the business of preparing, producing, converting, processing, packaging, labeling, or distributing a prescription drug, but not including a wholesale distributor or dispenser; (2) "Pharmacy,…

A pharmaceutical manufacturer may not, directly or indirectly, deny, restrict, or prohibit the acquisition of a 340B drug or the delivery of a 340B drug to a location that is authorized to receive the drug by a 340B entity or pharmacy, unless receipt of the 340B drug is prohibite…

A pharmaceutical manufacturer may not, directly or indirectly, require a 340B entity or pharmacy to submit any claim or utilization data, as a condition for allowing the acquisition of a 340B drug by, or delivery of a 340B drug to, a 340B entity, unless the claim or utilization d…

In addition to any other remedy provided by law, a 340B entity or a pharmacy may file a civil action against a pharmaceutical manufacturer for a violation of this chapter, and may request injunctive relief, actual and consequential damages, and reasonable attorneys' fees and cost…

Source: SL 1989, ch 436 , § 5.

Source: SL 2024, ch 204 , § 2.

Source: SL 1992, ch 353 , § 9.

58-30-1.2 "Rejected business" defined. 58-30-2

Excess business is that portion of a risk which is in excess of the amount that an insurer then represented by the insurance producer will accept. Source: SL 1982, ch 365 , § 6; SL 2001, ch 286 , § 154.

Rejected business is a risk that an insurer then represented by the insurance producer has rejected for underwriting reasons, or is willing to accept only on a substandard basis; but which business will be accepted and issued by another authorized insurer at a lower rate. Source:…