REFERENCE TITLE: pharmacy benefits managers; pharmacies; practices
State of Arizona
House of Representatives
Second Regular Session
Amending section 20‑3321, Arizona Revised Statutes; amending title 20, chapter 25, Arizona Revised Statutes, by adding article 2; relating to pharmacy benefits.
(TEXT OF BILL BEGINS ON NEXT PAGE)
Be it enacted by the Legislature of the State of Arizona:
Section 1. Section 20-3321, Arizona Revised Statutes, is amended to read:
In this article chapter, unless the context otherwise requires:
1. "Auditing entity" means any person, company, group or plan working on behalf of or pursuant to a contract with an insurer or pharmacy benefits manager for the purposes of auditing pharmacy drug claims adjudicated by pharmacies.
2. "Clerical errors" means a minor recordkeeping or transcribing error, including typographical errors, scrivner's errors or computer errors, in a required electronic or hard copy document, record or prescription order if both of the following criteria are met:
(a) The error did not result in actual financial harm to an entity.
(b) The error did not involve dispensing an incorrect dose or type of medication or dispensing a prescription drug to the wrong person.
3. "Desktop audit" means an audit that is conducted by an auditing entity at a location other than the location of the pharmacist or pharmacy. Desktop audit includes an audit that is performed at the offices of the auditing entity during which the pharmacist or pharmacy provides requested documents for review by hard copy or by microfiche, disk or other electronic media.
4. "In‑pharmacy audit" means an audit that is conducted by an auditing entity at the physical business address of the pharmacy where the claim was adjudicated.
5. "Insurer" means a disability insurer, group disability insurer, blanket disability insurer, health care services organization, hospital service corporation, medical service corporation or hospital and medical service corporation.
6. "Pharmacist" has the same meaning prescribed in section 32‑1901.
7. "Pharmacy" has the same meaning prescribed in section 32‑1901.
8. "Pharmacy benefits manager" means a person, business or other entity that, pursuant to a contract or under an employment relationship with a carrier an insurer or other third-party payer, either directly or through an intermediary manages the prescription drug coverage provided by the carrier insurer or other third-party payer, including the processing and payment of claims for prescription drugs, the performance of drug utilization review, the processing of drug prior authorization requests, the adjudication of appeals or grievances related to prescription drug coverage, contracting with network pharmacies and controlling the cost of covered prescription drugs.
Sec. 2. Title 20, chapter 25, Arizona Revised Statutes, is amended by adding article 2, to read:
ARTICLE 2. PHARMACY PATIENT FAIR PRACTICE ACT
In this article unless the context otherwise requires:
1. "Cost sharing requirement" means an enrollee's applicable coinsurance, copayment and deductible requirement under a health plan based on the adjudicated claim.
2. "Enrollee" means an individual who is covered by the prescription drug coverage provided by an insurer, managed care organization or other third‑party payer and managed by a pharmacy benefits manager.
20-3332. Pharmacy benefits manager; prohibitions; enforcement
A. A pharmacy benefits manager may not do any of the following:
1. Charge or collect from an enrollee a cost sharing requirement for a prescription or pharmacy service that exceeds the amount retained by the pharmacist or pharmacy from all payment sources for filling the prescription or providing the service.
2. Prohibit a pharmacist or pharmacy from doing either of the following:
(a) Informing an enrollee of the difference between the enrollee's cost sharing requirement for a prescription drug and the amount the enrollee would pay if the enrollee did not use prescription drug coverage to cover the cost.
(b) Selling a prescription drug to an enrollee who chooses not to use prescription drug coverage to cover the cost.
3. Prohibit or otherwise restrict a pharmacist or pharmacy from offering prescription delivery services to an enrollee.
4. Restrict a pharmacy from dispensing a ninety‑day fill of a prescription medication pursuant to Arizona state board of pharmacy rules. Efforts to restrict, prohibit or refer an enrollee to another pharmacy for this benefit is prohibited.
B. If the director believes that a pharmacy benefits manager has violated or is violating this article, the director may:
1. Issue a cease and desist order.
2. Assess a civil penalty.
3. Refer the matter to the attorney general for appropriate enforcement.
C. A person who is aggrieved by a violation of this section may institute a civil action in superior court.
This article applies to all contracts between a pharmacy benefits manager and a pharmacy or a pharmacy's contracting representative or agent that are entered into or renewed on or after the effective date of this article.