Montana Code 33-2-2406. Pharmacy benefit manager transparency to carriers and plan sponsors
33-2-2406. Pharmacy benefit manager transparency to carriers and plan sponsors. (1) Beginning in the second quarter after the effective date of a contract between a pharmacy benefit manager and a health carrier, plan sponsor, or workers’ compensation insurance carrier, the pharmacy benefit manager shall disclose, within 45 days of a request of the health carrier, plan sponsor, or workers’ compensation insurance carrier, the following information regarding prescription drug benefits specific to the health carrier, plan sponsor, or workers’ compensation insurance carrier:
Terms Used In Montana Code 33-2-2406
- Contract: A legal written agreement that becomes binding when signed.
- distributor: has the meaning provided in 37-7-602. See Montana Code 33-2-2402
- Enrollee: means a member, policyholder, subscriber, covered person, beneficiary, dependent, or other individual participating in a health benefit plan. See Montana Code 33-2-2402
- Health benefit plan: means a policy, contract, certificate, or agreement entered into, offered, or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. See Montana Code 33-2-2402
- Health carrier: means an entity that is subject to the insurance laws and regulations of this state or to the jurisdiction of the commissioner and that contracts or offers to contract or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. See Montana Code 33-2-2402
- Manufacturer: has the meaning provided in 37-7-602. See Montana Code 33-2-2402
- Pharmacy: means an established location, either physical or electronic, that is licensed by the board of pharmacy pursuant to Title 37, chapter 7. See Montana Code 33-2-2402
- Pharmacy benefit manager: means a person, including a wholly or partially owned or controlled subsidiary of a pharmacy benefit manager, that provides claims processing services or other prescription drug or device services, or both, to:
(i)enrollees who are residents of this state, for health benefit plans; or
(ii)injured workers of workers' compensation insurance carriers. See Montana Code 33-2-2402
- Plan sponsor: has the meaning provided in 33-10-202. See Montana Code 33-2-2402
- Rebates: means all price concessions, however characterized, paid by a manufacturer to a pharmacy benefit manager, including discounts and other remuneration or price concessions, that are based on the actual or estimated utilization of a prescription drug. See Montana Code 33-2-2402
(a)the aggregate wholesale acquisition costs from a manufacturer or wholesale distributor for each therapeutic category of prescription drugs;
(b)the aggregate wholesale acquisition costs from a manufacturer or wholesale distributor for each therapeutic category of prescription drugs available to enrollees of the health carrier or plan sponsor or injured workers of the workers’ compensation insurance carrier;
(c)the aggregate amount of rebates received by the pharmacy benefit manager by therapeutic category of prescription drugs;
(d)any other fees received from a manufacturer or wholesale distributor and the reason for the fees;
(e)whether the pharmacy benefit manager has a contract, agreement, or other arrangement with a manufacturer to exclusively dispense or provide a drug to enrollees of the health carrier or plan sponsor or injured workers of the workers’ compensation carrier, and the application of all consideration or economic benefits collected or received pursuant to the arrangement;
(f)prescription drug utilization information for enrollees of the health carrier or plan sponsor or injured workers of the workers’ compensation carrier, including but not limited to:
(i)the top 10 prescription drugs by average total spending for each enrollee or injured worker;
(ii)the top 10 prescription drugs by average out-of-pocket spending for each enrollee or injured worker;
(iii)the top 10 therapeutic classes of prescription drugs by total spending and volume;
(iv)the total number of pharmacy transactions; and
(v)the total number of rejected pharmacy transactions, including a breakdown of the number rejected for the following reasons:
(A)nonformulary status;
(B)prior authorization requirements; and
(C)step therapy requirements;
(g)deidentified claims-level information in electronic format that allows the health carrier, plan sponsor, or workers’ compensation insurance carrier to sort and analyze the following information for each claim:
(i)whether the claim required prior authorization;
(ii)the amount paid to the pharmacy for each prescription, net of the aggregate amount of fees or other assessments imposed on the pharmacy, including point-of-sale and retroactive charges;
(iii)any spread between the net amount paid to the pharmacy as described in subsection (1)(g)(ii) and the amount charged to the health carrier, plan sponsor, or workers’ compensation insurance carrier;
(iv)whether the pharmacy is or is not:
(A)under common control or ownership with the pharmacy benefit manager;
(B)a preferred pharmacy for the health benefit plan or workers’ compensation insurance carrier; or
(C)a mail-order pharmacy; and
(v)whether enrollees or injured workers are required by the health benefit plan or workers’ compensation insurance carrier to use the pharmacy;
(h)the aggregate amount of payments made by the pharmacy benefit manager on behalf of the health carrier, plan sponsor, or workers’ compensation insurance carrier to:
(i)pharmacies owned or controlled by the pharmacy benefit manager; and
(ii)pharmacies not owned or controlled by the pharmacy benefit manager; and
(i)the aggregate amount of the fees imposed on or collected from network pharmacies or other assessments against network pharmacies, including point-of-sale fees and retroactive charges, and the amount of fees passed on to the health carrier, plan sponsor, or workers’ compensation insurance carrier pursuant to the contract with the health carrier, plan sponsor, or workers’ compensation insurance carrier.
(2)A health carrier, plan sponsor, or workers’ compensation insurance carrier may request more detailed data from the pharmacy manager for any aggregate data provided under this section, including information to verify the pharmacy benefit manager’s source of and reported amounts of rebates and fees.
(3)A pharmacy benefit manager may require a health carrier, plan sponsor, or workers’ compensation insurance carrier to agree to a nondisclosure agreement that specifies that the information reported under this section is proprietary information. A pharmacy benefit manager requiring the use of a nondisclosure agreement is not required to disclose information under this section to the health carrier, plan sponsor, or workers’ compensation insurance carrier until the health carrier, plan sponsor, or workers’ compensation insurance carrier has executed the nondisclosure agreement.