Utah Code 31A-46-302. Direct or indirect remuneration by pharmacy benefit managers — Disclosure of customer costs — Limit on customer payment for prescription drugs
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(1) If a pharmacy service entity engages in direct or indirect remuneration with a pharmacy, the pharmacy service entity shall make a reimbursement report available to the pharmacy upon the pharmacy’s request.
Terms Used In Utah Code 31A-46-302
- Allowable claim amount: means the amount paid by an insurer under the customer's health benefit plan. See Utah Code 31A-46-102
- Contract: A legal written agreement that becomes binding when signed.
- Cost share: means the amount paid by an insured customer under the customer's health benefit plan. See Utah Code 31A-46-102
- Device: means the same as that term is defined in Section 58-17b-102. See Utah Code 31A-46-102
- Direct or indirect remuneration: means any adjustment in the total compensation:(9)(a) received by a pharmacy from a pharmacy benefit manager for the sale of a drug, device, or other product or service; and(9)(b) that is determined after the sale of the product or service. See Utah Code 31A-46-102
- Drug: means the same as that term is defined in Section 58-17b-102. See Utah Code 31A-46-102
- Insured: means a person to whom or for whose benefit an insurer makes a promise in an insurance policy and includes:
(103)(a)(i) a policyholder;(103)(a)(ii) a subscriber;(103)(a)(iii) a member; and(103)(a)(iv) a beneficiary. See Utah Code 31A-1-301- Pharmacist: means the same as that term is defined in Section 58-17b-102. See Utah Code 31A-46-102
- Pharmacy: means the same as that term is defined in Section 58-17b-102. See Utah Code 31A-46-102
- Pharmacy benefit manager: means a person licensed under this chapter to provide a pharmacy benefits management service. See Utah Code 31A-46-102
- Pharmacy service: means a product, good, or service provided to an individual by a pharmacy or pharmacist. See Utah Code 31A-46-102
- Pharmacy service entity: means :
(25)(a) a pharmacy services administration organization; or(25)(b) a pharmacy benefit manager. See Utah Code 31A-46-102- Prescription device: means the same as that term is defined in Section 58-17b-102. See Utah Code 31A-46-102
- Prescription drug: means the same as that term is defined in Section 58-17b-102. See Utah Code 31A-46-102
- Reimbursement report: means a report on the adjustment in total compensation for a claim. See Utah Code 31A-46-102
- Sale: means a prescription drug or prescription device claim covered by a health benefit plan. See Utah Code 31A-46-102
(2) For the reimbursement report described in Subsection (1), the pharmacy service entity shall:(2)(a) include the adjusted compensation amount related to a claim and the reason for the adjusted compensation; and(2)(b) provide the reimbursement report:(2)(b)(i) in accordance with the contract between the pharmacy and the pharmacy service entity;(2)(b)(ii) in an electronic format that is easily accessible; and(2)(b)(iii) within 120 days after the day on which the pharmacy benefit manager receives a report of a sale of a product or service by the pharmacy.(3) A pharmacy service entity shall, upon a pharmacy’s request, provide the pharmacy with:(3)(a) the reasons for any adjustments contained in a reimbursement report; and(3)(b) an explanation of the reasons provided in Subsection (3)(a).(4)(4)(a) A pharmacy benefit manager may not prohibit or penalize the disclosure by a pharmacist of:(4)(a)(i) an insured customer’s cost share for a covered prescription drug or prescription device;(4)(a)(ii) the availability of any therapeutically equivalent alternative medications; or(4)(a)(iii) alternative methods of paying for the prescription medication or prescription device, including paying the cash price, that are less expensive than the cost share of the prescription drug.(4)(b) Penalties that are prohibited under Subsection (4)(a) include increased utilization review, reduced payments, and other financial disincentives.(5) A pharmacy benefit manager may not require an insured customer to pay, for a covered prescription drug or prescription device, more than the lesser of:(5)(a) the applicable cost share of the prescription drug or prescription device being dispensed;(5)(b) the applicable allowable claim amount of the prescription drug or prescription device being dispensed;(5)(c) the applicable pharmacy reimbursement of the prescription drug or prescription device being dispensed; or(5)(d) the retail price of the prescription drug or prescription device without prescription drug coverage.(6) For a contract entered into or renewed on or after May 12, 2020, a pharmacy benefit manager may not engage in direct or indirect remuneration that results in a reduction in total compensation received by a pharmacy from the pharmacy benefit manager for the sale of a drug, device, or other product or service unless the pharmacy benefit manager provides the pharmacy with at least 30 days notice of the direct or indirect remuneration.