The Vermont Statutes Online

Title 8 : Banking and Insurance

Chapter 107 : Health Insurance

Subchapter 001 : GENERALLY

• § 4089j. Retail pharmacies; filling of prescriptions

  (a) As used in this section:

  (1) “Health insurer” shall have the same meaning as in 18 V.S.A. § 9402 and shall also include Medicaid and any other public health care assistance program.

  (2) “Pharmacy benefit manager” means an entity that performs pharmacy benefit management. “Pharmacy benefit management” means an arrangement for the procurement of prescription drugs at negotiated dispensing rates, the administration or management of prescription drug benefits provided by a health insurance plan for the benefit of beneficiaries, or any of the following services provided with regard to the administration of pharmacy benefits:

  (A) mail service pharmacy;

  (B) claims processing, retail network management, and payment of claims to pharmacies for prescription drugs dispensed to beneficiaries;

  (C) clinical formulary development and management services;

  (D) rebate contracting and administration;

  (E) certain patient compliance, therapeutic intervention, and generic substitution programs; and

  (F) disease management programs.

  (3) “Health care provider” means a person, partnership, or corporation, other than a facility or institution, that is licensed, certified, or otherwise authorized by law to provide professional health care services in this State to an individual during that individual’s medical care, treatment, or confinement.

  (4) “Pharmacy benefit manager affiliate” means a pharmacy or pharmacist that, directly or indirectly, through one or more intermediaries, is owned or controlled by, or is under common ownership or control with, a pharmacy benefit manager.

  (5) “Drug” or “prescription drug” has the same meaning as “prescription drug” in 26 V.S.A. § 2022 and includes:

  (A) biological products, as defined in 18 V.S.A. § 4601;

  (B) medications used to treat complex, chronic conditions, including medications that require administration, infusion, or injection by a health care professional;

  (C) medications for which the manufacturer or the U.S. Food and Drug Administration requires exclusive, restricted, or limited distribution; and

  (D) medications with specialized handling, storage, or inventory reporting requirements.

  (6) “Direct solicitation” means direct contact, including telephone, computer, e-mail, instant messaging, or in-person contact, by a pharmacy provider or its agent to a beneficiary of a plan offered by a health insurer without the beneficiary’s consent for the purpose of marketing the pharmacy provider’s services.

  (b) A health insurer or pharmacy benefit manager doing business in Vermont shall permit a retail pharmacist licensed under 26 V.S.A. chapter 36 to fill prescriptions for all prescription drugs in the same manner and at the same level of reimbursement as they are filled by any other pharmacist or pharmacy, including a mail-order pharmacy or a pharmacy benefit manager affiliate, with respect to the quantity of drugs or days’ supply of drugs dispensed under each prescription.

  (c) Notwithstanding any provision of a health insurance plan to the contrary, if a health insurance plan provides for payment or reimbursement that is within the lawful scope of practice of a pharmacist, the insurer may provide payment or reimbursement for the service when the service is provided by a pharmacist.

  (d)(1) A health insurer or pharmacy benefit manager shall permit a participating network pharmacy to perform all pharmacy services within the lawful scope of the profession of pharmacy as set forth in 26 V.S.A. chapter 36.

  (2) A health insurer or pharmacy benefit manager shall not do any of the following:

  (A) Require a covered individual, as a condition of payment or reimbursement, to purchase pharmacist services, including prescription drugs, exclusively through a mail-order pharmacy or a pharmacy benefit manager affiliate.

  (B) Offer or implement plan designs that require a covered individual to use a mail-order pharmacy or a pharmacy benefit manager affiliate.

  (C) Order a covered individual, orally or in writing, including through online messaging, to use a mail-order pharmacy or a pharmacy benefit manager affiliate.

  (D) Establish network requirements that are more restrictive than or inconsistent with State or federal law, rules adopted by the Board of Pharmacy, or guidance provided by the Board of Pharmacy or by drug manufacturers that operate to limit or prohibit a pharmacy or pharmacist from dispensing or prescribing drugs.

  (E) Offer or implement plan designs that increase plan or patient costs if the covered individual chooses not to use a mail-order pharmacy or a pharmacy benefit manager affiliate. The prohibition in this subdivision (E) includes requiring a covered individual to pay the full cost for a prescription drug when the covered individual chooses not to use a mail-order pharmacy or a pharmacy benefit manager affiliate.

  (F)(i) Exclude any amount paid by or on behalf of a covered individual, including any third-party payment, financial assistance, discount, coupon, or other reduction, when calculating a covered individual’s contribution toward:

  (I) the out-of-pocket limits for prescription drug costs under section 4089i of this title;

  (II) the covered individual’s deductible, if any; or

  (III) to the extent not inconsistent with Sec. 2707 of the Public Health Service Act, 42 U.S.C. § 300gg-6, the annual out-of-pocket maximums applicable to the covered individual’s health benefit plan.

  (ii) The provisions of subdivision (i) of this subdivision (F) relating to a third-party payment, financial assistance, discount, coupon, or other reduction in out-of-pocket expenses made on behalf of a covered person shall only apply to a prescription drug:

  (I) for which there is no generic drug or interchangeable biological product, as those terms are defined in 18 V.S.A. § 4601; or

  (II) for which there is a generic drug or interchangeable biological product, as those terms are defined in 18 V.S.A. § 4601, but for which the covered person has obtained access through prior authorization, a step therapy protocol, or the pharmacy benefit manager’s or health benefit plan’s exceptions and appeals process.

  (iii) The provisions of subdivision (i) of this subdivision (F) shall apply to a high-deductible health plan only to the extent that it would not disqualify the plan from eligibility for a health savings account pursuant to 26 U.S.C. § 223.

  (3) A health insurer or pharmacy benefit manager shall not, by contract, written policy, or written procedure, require that a pharmacy designated by the health insurer or pharmacy benefit manager dispense a medication directly to a patient with the expectation or intention that the patient will transport the medication to a health care setting for administration by a health care professional.

  (4) A health insurer or pharmacy benefit manager shall not, by contract, written policy, or written procedure, require that a pharmacy designated by the health insurer or pharmacy benefit manager dispense a medication directly to a health care setting for a health care professional to administer to a patient.

  (5) A health insurer or pharmacy benefit manager shall adhere to the definitions of prescription drugs and the requirements and guidance regarding the pharmacy profession established by State and federal law and the Vermont Board of Pharmacy and shall not establish classifications of or distinctions between prescription drugs, impose penalties on prescription drug claims, attempt to dictate the behavior of pharmacies or pharmacists, or place restrictions on pharmacies or pharmacists that are more restrictive than or inconsistent with State or federal law or with rules adopted or guidance provided by the Board of Pharmacy.

  (6) A pharmacy benefit manager or licensed pharmacy shall not make a direct solicitation to the beneficiary of a plan offered by a health insurer unless one or more of the following applies:

  (A) the beneficiary has given written permission to the supplier or the ordering health care professional to contact the beneficiary regarding the furnishing of a prescription item that is to be rented or purchased;

  (B) the supplier has furnished a prescription item to the beneficiary and is contacting the beneficiary to coordinate delivery of the item; or

  (C) if the contact relates to the furnishing of a prescription item other than a prescription item already furnished to the beneficiary, the supplier has furnished at least one prescription item to the beneficiary within the 15-month period preceding the date on which the supplier attempts to make the contact.

  (7) The provisions of this subsection shall not apply to Medicaid.

  (e) A health insurer or pharmacy benefit manager shall not alter a patient’s prescription drug order or the pharmacy chosen by the patient without the patient’s consent; provided, however, that nothing in this subsection shall be construed to affect the duty of a pharmacist to substitute a lower-cost drug or biological product in accordance with the provisions of 18 V.S.A. § 4605. (Added 2003, No. 122 (Adj. Sess.), § 128e; amended 2013, No. 79, § 9, eff. Jan. 1, 2014; 2015, No. 173 (Adj. Sess.), § 7, eff. June 8, 2016; 2021, No. 131 (Adj. Sess.), § 4, eff. January 1, 2023; 2023, No. 127 (Adj. Sess.), § 3, eff. July 1, 2024.)