Sec. 19. (a) A pharmacy benefit manager shall provide equal access and incentives to all pharmacies within the pharmacy benefit manager's network.
(b) A pharmacy benefit manager may not do any of the following:
(1) Condition participation in any network on accreditation, credentialing, or licensing of a pharmacy, other than a license or permit required by the Indiana board of pharmacy or other state or federal regulatory authority for the services provided by the pharmacy. However, nothing in this subdivision precludes the department from providing credentialing or accreditation standards for pharmacies.
(2) Discriminate against any pharmacy.
(3) Directly or indirectly retroactively deny a claim or aggregate of claims after the claim or aggregate of claims has been adjudicated, unless any of the following apply:
(A) The original claim was submitted fraudulently.
(B) The original claim payment was incorrect because the pharmacy or pharmacist had already been paid for the drug.
(C) The pharmacist services were not properly rendered by the pharmacy or pharmacist.
(4) Reduce, directly or indirectly, payment to a pharmacy for pharmacist services to an effective rate of reimbursement, including permitting an insurer or plan sponsor to make such a reduction.
(5) Reimburse a pharmacy that is affiliated with the pharmacy benefit manager, other than solely being included in the pharmacy benefit manager's network, at a greater reimbursement rate than other pharmacies in the same network.
(6) Impose limits, including quantity limits or refill frequency limits, on a pharmacy's access to medication that differ from those existing for a pharmacy benefit manager affiliate.
(7) Share any covered individual's information, including de-identified covered individual information, received from a pharmacy or pharmacy benefit manager affiliate, except as permitted by the federal Health Insurance Portability and Accountability Act (HIPAA) (P.L.104-191).
A violation of this subsection by a pharmacy benefit manager constitutes an unfair or deceptive act or practice in the business of insurance under IC 27-4-1-4.
As added by P.L.68-2020, SEC.1. Amended by P.L.32-2021, SEC.78; P.L.196-2021, SEC.22.
Structure Indiana Code
Article 1. Department of Insurance
Chapter 24.5. Pharmacy Benefit Managers
27-1-24.5-1. "Covered Individual"
27-1-24.5-2. "Effective Rate of Reimbursement"
27-1-24.5-3. "Equal Access and Incentives"
27-1-24.5-6. "Independent Pharmacies"
27-1-24.5-7. "Maximum Allowable Cost"
27-1-24.5-8. "Maximum Allowable Cost List"
27-1-24.5-10. "Pharmacist Services"
27-1-24.5-12. "Pharmacy Benefit Manager"
27-1-24.5-13. "Pharmacy Benefit Manager Affiliate"
27-1-24.5-14. "Pharmacy Benefit Manager Network"
27-1-24.5-15. "Pharmacy Services Administrative Organization"
27-1-24.5-19. Equal Access and Incentives; Prohibited Acts
27-1-24.5-19.5. Federal Drug Pricing Program
27-1-24.5-20. Acts of the Commissioner; Confidentiality
27-1-24.5-21. Annual Reporting Requirements; Trade Secrets
27-1-24.5-22. Required Information; Appeals Process; Auditing Procedures
27-1-24.5-22.5. Aggregated Information From Pharmacy Benefit Manager Reports
27-1-24.5-22.6. Filing Complaints With Department of Insurance
27-1-24.5-24. Information Necessary for Appeal
27-1-24.5-25. Party's Right to Audit; Amounts Paid; Consideration
27-1-24.5-26. Disclosure of Contract With Another Party
27-1-24.5-27. Contracts of Pharmacy Services Administrative Organizations
27-1-24.5-27.5. Pharmacist May Not Be Required to Collect Higher Copayment for Prescription Drug