§ 449. Medical assistance pharmacy services
Purdon's Pennsylvania Statutes and Consolidated StatutesTitle 62 P.S. Poor Persons and Public WelfareEffective: January 25, 2021
Effective: January 25, 2021
62 P.S. § 449
§ 449. Medical assistance pharmacy services
<Section 3 of 2020, Nov. 25, P.L. 1208, No. 120, effective in 60 days [Jan. 25, 2021], provides that the amendment of this section shall apply to any agreement or contract relating to pharmacy services to medical assistance recipients in the managed care delivery system entered into or amended on or after Jan. 25, 2021.>
(a) Any managed care organization under contract to the department, or an entity with which the managed care organization contracts, must contract on an equal basis with any pharmacy qualified to participate in the Medical Assistance Program that is willing to comply with the managed care organization's or entity's pharmacy payment rates and terms and to adhere to quality standards established by the managed care organization or entity.
(e) Information disclosed or produced by an entity to the department under this section shall not be subject to public access under the act of February 14, 2008 (P.L. 6, No. 3),1 known as the “Right-to-Know Law.”
(1) Require that a pharmacist or pharmacy participate in a network managed by the pharmacy benefit manager or pharmacy services administration organization as a condition for the pharmacist or pharmacy to participate in another network managed by the same pharmacy benefit manager or pharmacy services administration organization.
“Adjudicated claim” means a claim that has been processed to payment or denial.
“Entity” means a pharmacy, pharmacy benefit manager, pharmacy services administration organization or other entity that manages, processes or influences the payment for or dispenses pharmacy services to medical assistance recipients in the managed care delivery system.
“Pharmacy benefit management” means any of the following:
(1) The procurement of prescription drugs at a negotiated contracted rate for distribution within this Commonwealth.
(2) The administration or management of prescription drug benefits provided by a managed care organization.
(3) The administration of pharmacy benefits, including any of the following:
(i) Operating a mail-service pharmacy.
(ii) Processing claims.
(iii) Managing a retail pharmacy network.
(iv) Paying claims to pharmacies, including retail, specialty or mail-order pharmacies, for prescription drugs dispensed to medical assistance recipients receiving services in the managed care delivery system via a retail or mail-order pharmacy.
(v) Developing and managing a clinical formulary or preferred drug list, utilization management or quality assurance programs.
(vi) Rebate contracting and administration.
(vii) Managing a patient compliance, therapeutic intervention and generic substitution program.
(viii) Operating a disease management program.
(ix) Setting pharmacy payment pricing and methodologies, including maximum allowable cost and determining single or multiple source drugs.
“Pharmacy benefit manager” means a business that performs pharmacy benefit management. The term does not include a business that holds a valid license from the Insurance Department with accident and health authority to issue a health insurance policy and governed under any of the following:
(1) The act of May 17, 1921 (P.L. 682, No. 284),2 known as “The Insurance Company Law of 1921.”
(2) The act of December 29, 1972 (P.L. 1701, No. 364),3 known as the “Health Maintenance Organization Act.”
(3) 40 Pa.C.S. Ch. 61 (relating to hospital plan corporations) or 63 (relating to professional health services plan corporations).
“Pharmacy services administration organization” means an organization comprised of pharmacy members that performs any of the following:
(1) Negotiates or contracts with a managed care organization or pharmacy benefit manager on behalf of its pharmacy members.
(2) Negotiates payment rates, payments or audit terms on behalf of its pharmacy members.
(3) Collects or reconciles payments on behalf of its pharmacy members.
Credits
1967, June 13, P.L. 31, No. 21, art. 4, § 449, added 1996, May 16, P.L. 175, No. 35, § 16, imd. effective. Amended 2020, Nov. 25, P.L. 1208, No. 120, § 1, effective in 60 days [Jan. 25, 2021].
62 P.S. § 449, PA ST 62 P.S. § 449
Current through Act 13 of the 2024 Regular Session. Some statute sections may be more current, see credits for details.
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