A. Notwithstanding any other provision in this chapter, no health maintenanceorganization providing health care plans shall prohibit any person receivingpharmaceutical benefits thereunder from selecting, without limitation, thepharmacy of his choice to furnish such benefits. This right of selectionextends to and includes pharmacies that are not participating providers underany such health care plan and that have previously notified the healthmaintenance organization, by facsimile or otherwise, of their agreement toaccept reimbursement for their services at rates applicable to pharmaciesthat are participating providers, including any copayment consistentlyimposed by the plan, as payment in full. Each health maintenance organizationshall permit prompt electronic or telephonic transmittal of the reimbursementagreement by the pharmacy and ensure prompt verification to the pharmacy ofthe terms of reimbursement. In no event shall any person receiving a coveredpharmacy benefit from a nonparticipating provider which has submitted areimbursement agreement be responsible for amounts that may be charged by thenonparticipating provider in excess of the copayment and the healthmaintenance organization's reimbursement applicable to all of itsparticipating pharmacy providers.
B. No such health maintenance organization shall impose upon any personreceiving pharmaceutical benefits furnished under any such health care plan:
1. Any copayment, fee or condition that is not equally imposed upon allindividuals in the same benefit category, class or copayment level, whetheror not such benefits are furnished by pharmacists who are not participatingproviders;
2. Any monetary penalty that would affect or influence any such person'schoice of pharmacy; or
3. Any reduction in allowable reimbursement for pharmacy services related toutilization of pharmacists who are not participating providers.
C. For purposes of this section, a prohibited condition or penalty shallinclude, without limitation: (i) denying immediate access to electronicclaims filing to a pharmacy that is a nonparticipating provider and that hascomplied with subsection E or (ii) requiring a person receiving pharmacybenefits to make payment at point of service, except to the extent suchconditions and penalties are similarly imposed on participating providers.
D. The provisions of this section are not applicable to any pharmaceuticalbenefit covered by a health care plan when those benefits are obtained from apharmacy wholly owned and operated by, or exclusively operated for, thehealth maintenance organization providing the health care plan.
E. Any pharmacy that wishes to be covered by this section shall, if requestedto do so in writing by a health maintenance organization, within 30 days ofthe pharmacy's receipt of the request, execute and deliver to the healthmaintenance organization the direct service agreement or participatingprovider agreement that the health maintenance organization requires all ofits participating providers of pharmacy benefits to execute. Any pharmacythat fails to timely execute and deliver such agreement shall not be coveredby this section with respect to that health maintenance organization unlessand until the pharmacy executes and delivers the agreement.
F. The Commission shall have no jurisdiction to adjudicate controversiesarising out of this section.
G. Nothing in this section shall limit the authority of a health maintenanceorganization providing health care plans to select a single mail orderpharmacy provider as the exclusive provider of pharmacy services that aredelivered to the covered person's address by mail, common carrier, ordelivery service. The provisions of this section shall not apply to suchcontracts. As used in this subsection, "mail order pharmacy provider" meansa pharmacy permitted to conduct business in the Commonwealth whose primarybusiness is to dispense a prescription drug or device under a prescriptivedrug order and to deliver the drug or device to a patient primarily by mail,common carrier, or delivery service.
(1994, c. 963; 1995, cc. 446, 467; 2010, cc. 157, 357.)
A. Notwithstanding any other provision in this chapter, no health maintenanceorganization providing health care plans shall prohibit any person receivingpharmaceutical benefits thereunder from selecting, without limitation, thepharmacy of his choice to furnish such benefits. This right of selectionextends to and includes pharmacies that are not participating providers underany such health care plan and that have previously notified the healthmaintenance organization, by facsimile or otherwise, of their agreement toaccept reimbursement for their services at rates applicable to pharmaciesthat are participating providers, including any copayment consistentlyimposed by the plan, as payment in full. Each health maintenance organizationshall permit prompt electronic or telephonic transmittal of the reimbursementagreement by the pharmacy and ensure prompt verification to the pharmacy ofthe terms of reimbursement. In no event shall any person receiving a coveredpharmacy benefit from a nonparticipating provider which has submitted areimbursement agreement be responsible for amounts that may be charged by thenonparticipating provider in excess of the copayment and the healthmaintenance organization's reimbursement applicable to all of itsparticipating pharmacy providers.
B. No such health maintenance organization shall impose upon any personreceiving pharmaceutical benefits furnished under any such health care plan:
1. Any copayment, fee or condition that is not equally imposed upon allindividuals in the same benefit category, class or copayment level, whetheror not such benefits are furnished by pharmacists who are not participatingproviders;
2. Any monetary penalty that would affect or influence any such person'schoice of pharmacy; or
3. Any reduction in allowable reimbursement for pharmacy services related toutilization of pharmacists who are not participating providers.
C. For purposes of this section, a prohibited condition or penalty shallinclude, without limitation: (i) denying immediate access to electronicclaims filing to a pharmacy that is a nonparticipating provider and that hascomplied with subsection E or (ii) requiring a person receiving pharmacybenefits to make payment at point of service, except to the extent suchconditions and penalties are similarly imposed on participating providers.
D. The provisions of this section are not applicable to any pharmaceuticalbenefit covered by a health care plan when those benefits are obtained from apharmacy wholly owned and operated by, or exclusively operated for, thehealth maintenance organization providing the health care plan.
E. Any pharmacy that wishes to be covered by this section shall, if requestedto do so in writing by a health maintenance organization, within 30 days ofthe pharmacy's receipt of the request, execute and deliver to the healthmaintenance organization the direct service agreement or participatingprovider agreement that the health maintenance organization requires all ofits participating providers of pharmacy benefits to execute. Any pharmacythat fails to timely execute and deliver such agreement shall not be coveredby this section with respect to that health maintenance organization unlessand until the pharmacy executes and delivers the agreement.
F. The Commission shall have no jurisdiction to adjudicate controversiesarising out of this section.
G. Nothing in this section shall limit the authority of a health maintenanceorganization providing health care plans to select a single mail orderpharmacy provider as the exclusive provider of pharmacy services that aredelivered to the covered person's address by mail, common carrier, ordelivery service. The provisions of this section shall not apply to suchcontracts. As used in this subsection, "mail order pharmacy provider" meansa pharmacy permitted to conduct business in the Commonwealth whose primarybusiness is to dispense a prescription drug or device under a prescriptivedrug order and to deliver the drug or device to a patient primarily by mail,common carrier, or delivery service.
(1994, c. 963; 1995, cc. 446, 467; 2010, cc. 157, 357.)
A. Notwithstanding any other provision in this chapter, no health maintenanceorganization providing health care plans shall prohibit any person receivingpharmaceutical benefits thereunder from selecting, without limitation, thepharmacy of his choice to furnish such benefits. This right of selectionextends to and includes pharmacies that are not participating providers underany such health care plan and that have previously notified the healthmaintenance organization, by facsimile or otherwise, of their agreement toaccept reimbursement for their services at rates applicable to pharmaciesthat are participating providers, including any copayment consistentlyimposed by the plan, as payment in full. Each health maintenance organizationshall permit prompt electronic or telephonic transmittal of the reimbursementagreement by the pharmacy and ensure prompt verification to the pharmacy ofthe terms of reimbursement. In no event shall any person receiving a coveredpharmacy benefit from a nonparticipating provider which has submitted areimbursement agreement be responsible for amounts that may be charged by thenonparticipating provider in excess of the copayment and the healthmaintenance organization's reimbursement applicable to all of itsparticipating pharmacy providers.
B. No such health maintenance organization shall impose upon any personreceiving pharmaceutical benefits furnished under any such health care plan:
1. Any copayment, fee or condition that is not equally imposed upon allindividuals in the same benefit category, class or copayment level, whetheror not such benefits are furnished by pharmacists who are not participatingproviders;
2. Any monetary penalty that would affect or influence any such person'schoice of pharmacy; or
3. Any reduction in allowable reimbursement for pharmacy services related toutilization of pharmacists who are not participating providers.
C. For purposes of this section, a prohibited condition or penalty shallinclude, without limitation: (i) denying immediate access to electronicclaims filing to a pharmacy that is a nonparticipating provider and that hascomplied with subsection E or (ii) requiring a person receiving pharmacybenefits to make payment at point of service, except to the extent suchconditions and penalties are similarly imposed on participating providers.
D. The provisions of this section are not applicable to any pharmaceuticalbenefit covered by a health care plan when those benefits are obtained from apharmacy wholly owned and operated by, or exclusively operated for, thehealth maintenance organization providing the health care plan.
E. Any pharmacy that wishes to be covered by this section shall, if requestedto do so in writing by a health maintenance organization, within 30 days ofthe pharmacy's receipt of the request, execute and deliver to the healthmaintenance organization the direct service agreement or participatingprovider agreement that the health maintenance organization requires all ofits participating providers of pharmacy benefits to execute. Any pharmacythat fails to timely execute and deliver such agreement shall not be coveredby this section with respect to that health maintenance organization unlessand until the pharmacy executes and delivers the agreement.
F. The Commission shall have no jurisdiction to adjudicate controversiesarising out of this section.
G. Nothing in this section shall limit the authority of a health maintenanceorganization providing health care plans to select a single mail orderpharmacy provider as the exclusive provider of pharmacy services that aredelivered to the covered person's address by mail, common carrier, ordelivery service. The provisions of this section shall not apply to suchcontracts. As used in this subsection, "mail order pharmacy provider" meansa pharmacy permitted to conduct business in the Commonwealth whose primarybusiness is to dispense a prescription drug or device under a prescriptivedrug order and to deliver the drug or device to a patient primarily by mail,common carrier, or delivery service.
(1994, c. 963; 1995, cc. 446, 467; 2010, cc. 157, 357.)
