Michigan Laws 550.926 – 340B Program entities; reimbursement, co-pay, and discrimination prohibitions; definitions
Current as of: 2024 | Check for updates
|
Other versions
Terms Used In Michigan Laws 550.926
- Carrier: means an insurer, including a health maintenance organization, regulated under the insurance code of 1956, 1956 PA 218, MCL 500. See Michigan Laws 550.902
- Claim: means a request for payment for administering, filling, or refilling a drug or for providing a pharmacy service or a medical supply or device to an enrollee as that term is defined in section 116 of the insurance code of 1956, 1956 PA 218, MCL 500. See Michigan Laws 550.902
- Contract: A legal written agreement that becomes binding when signed.
- manager: means an individual responsible for conducting the daily operations of a third party administrator. See Michigan Laws 550.902
- Manufacturer: means that term as defined in section 17706 of the public health code, 1978 PA 368, MCL 333. See Michigan Laws 550.902
- Pharmacy: means that term as defined in section 17707 of the public health code, 1978 PA 368, MCL 333. See Michigan Laws 550.902
- pharmacy benefit manager: means an entity that contracts with a pharmacy or a pharmacy services administration organization on behalf of a health plan or carrier to provide pharmacy health services to individuals covered by the health plan or carrier or administration that includes, but is not limited to, any of the following:
(i) Contracting directly or indirectly with pharmacies to provide drugs to enrollees or other covered persons. See Michigan Laws 550.902rebate: means a formulary discount or remuneration attributable to the use of prescription drugs that is paid by a manufacturer or third party, directly or indirectly, to a pharmacy benefit manager after a claim has been adjudicated at a pharmacy. See Michigan Laws 550.902 state: when applied to the different parts of the United States, shall be construed to extend to and include the District of Columbia and the several territories belonging to the United States; and the words "United States" shall be construed to include the district and territories. See Michigan Laws 8.3o
(1) A carrier or third party administrator that is a pharmacy benefit manager shall not prohibit a 340B Program entity or a pharmacy that has a license in good standing in this state under contract with a 340B Program entity from participating in the carrier’s or third party administrator that is a pharmacy benefit manager‘s provider network solely because it is a 340B Program entity or a pharmacy under contract with a 340B Program entity. A carrier or third party administrator that is a pharmacy benefit manager shall not reimburse a 340B Program entity or a pharmacy under contract with a 340B Program entity differently than other similarly situated pharmacies. As used in this subsection, “340B Program entity” means an entity authorized to participate in the federal 340B Program under section 340B of the public health service act, 42 USC 256b.
(2) A carrier or other third party, or a third party administrator that is a pharmacy benefit manager, shall not, except as required by law to prevent a duplicate rebate, require a claim for a drug to include a modifier or otherwise to indicate that the drug is a 340B drug unless the claim is for payment, directly or indirectly, by the Medicaid program. As used in this subsection:
(a) “Medicaid program” means the program for medical assistance established under title XIX of the social security act, 42 USC 1396 to 1396w-6.
(b) “Rebate” means a formulary discount or remuneration attributable to the use of prescription drugs that is paid by a manufacturer or third party, directly or indirectly, to a pharmacy benefit manager after a claim has been adjudicated at a pharmacy. Rebate does not include a fee, including, but not limited to, a bona fide service fee or administrative fee, that is not a formulary discount or remuneration described in this subdivision.
(c) “Third party” does not include a pharmacy benefit manager or carrier.
(d) “340B drug” means a covered drug as that term is defined in 42 USC 256b.
(3) A third party administrator that is a pharmacy benefit manager shall not exclude or discriminate against a pharmacy solely based on the carrier not having a vested financial interest in the pharmacy. As used in this subsection, “having a vested financial interest” means having ownership, having co-ownership, being a shareholder, or having another connection from which financial gain or loss could be realized.