(a)  Any pharmacies licensed in the state of Rhode Island that are not owned or controlled, directly or indirectly, by an entity that owns pharmacies licensed in two (2) or more jurisdictions other than Rhode Island, which are not participating in an insurer’s restricted pharmacy network contract shall nevertheless have the right to provide prescription drug services to the insurer’s insureds and be paid by the insurer as if the pharmacy were participating in the insurer’s restricted pharmacy network, provided that the non-network independent pharmacies agree:

(1)  To accept as the insurer’s payments in full the price required of pharmacies in the insurer’s restricted pharmacy network;

(2)  To bill to the insured up to and not in excess of any copayment, coinsurance, deductible, other amount required of an insured by the insurer, or for other uncovered services;

(3)  To be reimbursed on the same methodological basis, including, but not limited to, capitation or other risk-sharing methodology, as required of pharmacies, in the insurer’s restricted pharmacy network;

(4)  To participate in the insurer’s utilization review and quality assurance programs, including utilization and drug management reports as required of pharmacies in the carrier’s restricted pharmacy network;

(5)  To provide computerized online eligibility determinations and claims submissions as required of pharmacies in the insurer’s restricted pharmacy network;

(6)  To participate in the insurer’s satisfaction surveys and complaint resolution programs for its insureds;

(7)  To protect the insurer’s proprietary information and an insured’s confidentiality and privacy;

(8)  To abide by the insurer’s performance standards with respect to waiting times, fill rates, and inventory management, including formulary restrictions;

(9)  To comply with the insurer’s claims audit provisions; and

(10)  To certify, using audit results or accountant statements, the fiscal soundness of the non-network pharmacy.

Ask an insurance law question, get an answer ASAP!
Click here to chat with a lawyer about your rights.

(b)  An insurer may waive any of the aforementioned agreements in arranging for the provision of pharmaceutical drug benefits to insureds through a non-network pharmacy. An insurer shall not impose any agreements, terms, or conditions on any non-network independent community pharmacy, or on any association of pharmacies, that are more restrictive than those required of pharmacies in the insurer’s restricted pharmacy network. The failure of a non-network pharmacy to abide by the aforementioned agreements may, at the option of the insurer, serve as the basis for cancellation of the non-network pharmacy’s participation.