Pharmacist, emergency situation, may take an assignment of enrollee'sright to reimbursement--health maintenance organizations shallonly contract with entities licensed by the board ofpharmacy--requirements for drug prescriptions, exceptions.
354.535. 1. If a pharmacy, operated by or contracted with by ahealth maintenance organization, is closed or is unable to provide healthcare services to an enrollee in an emergency, a pharmacist may take anassignment of such enrollee's right to reimbursement, if the policy orcontract provides for such reimbursement, for those goods or servicesprovided to an enrollee of a health maintenance organization. No healthmaintenance organization shall refuse to pay the pharmacist any payment duethe enrollee under the terms of the policy or contract.
2. No health maintenance organization, conducting business in thestate of Missouri, shall contract with a pharmacy, pharmacy distributor orwholesale drug distributor, nonresident or otherwise, unless such pharmacyor distributor has been granted a permit or license from the Missouri boardof pharmacy to operate in this state.
3. Every health maintenance organization shall apply the samecoinsurance, co-payment and deductible factors to all drug prescriptionsfilled by a pharmacy provider who participates in the health maintenanceorganization's network if the provider meets the contract's explicitproduct cost determination. If any such contract is rejected by anypharmacy provider, the health maintenance organization may offer othercontracts necessary to comply with any network adequacy provisions of thisact*. However, nothing in this section shall be construed to prohibit thehealth maintenance organization from applying different coinsurance,co-payment and deductible factors between generic and brand name drugs.
4. Health maintenance organizations shall not set a limit on thequantity of drugs which an enrollee may obtain at any one time with aprescription, unless such limit is applied uniformly to all pharmacyproviders in the health maintenance organization's network.
5. Health maintenance organizations shall not insist or mandate anyphysician or other licensed health care practitioner to change anenrollee's maintenance drug unless the provider and enrollee agree to suchchange. For the purposes of this provision, a maintenance drug shall meana drug prescribed by a practitioner who is licensed to prescribe drugs,used to treat a medical condition for a period greater than thirty days.Violations of this provision shall be subject to the penalties provided insection 354.444. Notwithstanding other provisions of law to the contrary,health maintenance organizations that change an enrollee's maintenance drugwithout the consent of the provider and enrollee shall be liable for anydamages resulting from such change. Nothing in this subsection, however,shall apply to the dispensing of generically equivalent products forprescribed brand name maintenance drugs as set forth in section 338.056,RSMo.
*"This act" in 1997 referred to H.B. 335, 1997, which contained numerous sections. "This act" now also includes H.B. 1302, 1998. Consult Disposition of Sections tables for both years for definitive listings.
(2000) Section is not preempted by Employee Retirement Income Security Act (ERISA). Express Scripts, Inc. v. Wenzel, 102 F.Supp.2d 1135 (W.D.Mo.).
(2001) Section falls within savings clause of Employee Retirement Income Security Act (ERISA) as a regulation of insurance. Express Scripts, Inc. v. Wenzel, 262 F.3d 829 (8th Cir.).
Pharmacist, emergency situation, may take an assignment of enrollee'sright to reimbursement--health maintenance organizations shallonly contract with entities licensed by the board ofpharmacy--requirements for drug prescriptions, exceptions.
354.535. 1. If a pharmacy, operated by or contracted with by ahealth maintenance organization, is closed or is unable to provide healthcare services to an enrollee in an emergency, a pharmacist may take anassignment of such enrollee's right to reimbursement, if the policy orcontract provides for such reimbursement, for those goods or servicesprovided to an enrollee of a health maintenance organization. No healthmaintenance organization shall refuse to pay the pharmacist any payment duethe enrollee under the terms of the policy or contract.
2. No health maintenance organization, conducting business in thestate of Missouri, shall contract with a pharmacy, pharmacy distributor orwholesale drug distributor, nonresident or otherwise, unless such pharmacyor distributor has been granted a permit or license from the Missouri boardof pharmacy to operate in this state.
3. Every health maintenance organization shall apply the samecoinsurance, co-payment and deductible factors to all drug prescriptionsfilled by a pharmacy provider who participates in the health maintenanceorganization's network if the provider meets the contract's explicitproduct cost determination. If any such contract is rejected by anypharmacy provider, the health maintenance organization may offer othercontracts necessary to comply with any network adequacy provisions of thisact*. However, nothing in this section shall be construed to prohibit thehealth maintenance organization from applying different coinsurance,co-payment and deductible factors between generic and brand name drugs.
4. Health maintenance organizations shall not set a limit on thequantity of drugs which an enrollee may obtain at any one time with aprescription, unless such limit is applied uniformly to all pharmacyproviders in the health maintenance organization's network.
5. Health maintenance organizations shall not insist or mandate anyphysician or other licensed health care practitioner to change anenrollee's maintenance drug unless the provider and enrollee agree to suchchange. For the purposes of this provision, a maintenance drug shall meana drug prescribed by a practitioner who is licensed to prescribe drugs,used to treat a medical condition for a period greater than thirty days.Violations of this provision shall be subject to the penalties provided insection 354.444. Notwithstanding other provisions of law to the contrary,health maintenance organizations that change an enrollee's maintenance drugwithout the consent of the provider and enrollee shall be liable for anydamages resulting from such change. Nothing in this subsection, however,shall apply to the dispensing of generically equivalent products forprescribed brand name maintenance drugs as set forth in section 338.056,RSMo.
*"This act" in 1997 referred to H.B. 335, 1997, which contained numerous sections. "This act" now also includes H.B. 1302, 1998. Consult Disposition of Sections tables for both years for definitive listings.
(2000) Section is not preempted by Employee Retirement Income Security Act (ERISA). Express Scripts, Inc. v. Wenzel, 102 F.Supp.2d 1135 (W.D.Mo.).
(2001) Section falls within savings clause of Employee Retirement Income Security Act (ERISA) as a regulation of insurance. Express Scripts, Inc. v. Wenzel, 262 F.3d 829 (8th Cir.).
Pharmacist, emergency situation, may take an assignment of enrollee'sright to reimbursement--health maintenance organizations shallonly contract with entities licensed by the board ofpharmacy--requirements for drug prescriptions, exceptions.
354.535. 1. If a pharmacy, operated by or contracted with by ahealth maintenance organization, is closed or is unable to provide healthcare services to an enrollee in an emergency, a pharmacist may take anassignment of such enrollee's right to reimbursement, if the policy orcontract provides for such reimbursement, for those goods or servicesprovided to an enrollee of a health maintenance organization. No healthmaintenance organization shall refuse to pay the pharmacist any payment duethe enrollee under the terms of the policy or contract.
2. No health maintenance organization, conducting business in thestate of Missouri, shall contract with a pharmacy, pharmacy distributor orwholesale drug distributor, nonresident or otherwise, unless such pharmacyor distributor has been granted a permit or license from the Missouri boardof pharmacy to operate in this state.
3. Every health maintenance organization shall apply the samecoinsurance, co-payment and deductible factors to all drug prescriptionsfilled by a pharmacy provider who participates in the health maintenanceorganization's network if the provider meets the contract's explicitproduct cost determination. If any such contract is rejected by anypharmacy provider, the health maintenance organization may offer othercontracts necessary to comply with any network adequacy provisions of thisact*. However, nothing in this section shall be construed to prohibit thehealth maintenance organization from applying different coinsurance,co-payment and deductible factors between generic and brand name drugs.
4. Health maintenance organizations shall not set a limit on thequantity of drugs which an enrollee may obtain at any one time with aprescription, unless such limit is applied uniformly to all pharmacyproviders in the health maintenance organization's network.
5. Health maintenance organizations shall not insist or mandate anyphysician or other licensed health care practitioner to change anenrollee's maintenance drug unless the provider and enrollee agree to suchchange. For the purposes of this provision, a maintenance drug shall meana drug prescribed by a practitioner who is licensed to prescribe drugs,used to treat a medical condition for a period greater than thirty days.Violations of this provision shall be subject to the penalties provided insection 354.444. Notwithstanding other provisions of law to the contrary,health maintenance organizations that change an enrollee's maintenance drugwithout the consent of the provider and enrollee shall be liable for anydamages resulting from such change. Nothing in this subsection, however,shall apply to the dispensing of generically equivalent products forprescribed brand name maintenance drugs as set forth in section 338.056,RSMo.
*"This act" in 1997 referred to H.B. 335, 1997, which contained numerous sections. "This act" now also includes H.B. 1302, 1998. Consult Disposition of Sections tables for both years for definitive listings.
(2000) Section is not preempted by Employee Retirement Income Security Act (ERISA). Express Scripts, Inc. v. Wenzel, 102 F.Supp.2d 1135 (W.D.Mo.).
(2001) Section falls within savings clause of Employee Retirement Income Security Act (ERISA) as a regulation of insurance. Express Scripts, Inc. v. Wenzel, 262 F.3d 829 (8th Cir.).
