The Vermont Statutes Online

Title 18 : Health

Chapter 077 : Pharmacy Benefit Managers

Subchapter 002 : PHARMACY BENEFIT MANAGER LICENSURE AND REGULATION

• § 3612. Prohibited practices

  (a) A participation contract between a pharmacy benefit manager and a pharmacist shall not prohibit, restrict, or penalize a pharmacy or pharmacist in any way from disclosing to any covered person any health care information that the pharmacy or pharmacist deems appropriate, including:

  (1) the nature of treatment, risks, or alternatives to treatment;

  (2) the availability of alternate therapies, consultations, or tests;

  (3) the decision of utilization reviewers or similar persons to authorize or deny services;

  (4) the process that is used to authorize or deny health care services; or

  (5) information on financial incentives and structures used by the health insurer.

  (b) A pharmacy benefit manager shall not prohibit a pharmacy or pharmacist from:

  (1) discussing information regarding the total cost for pharmacist services for a prescription drug;

  (2) providing information to a covered person regarding the covered person’s cost-sharing amount for a prescription drug;

  (3) disclosing to a covered person the cash price for a prescription drug; or

  (4) selling a more affordable alternative to the covered person if a more affordable alternative is available.

  (c) A pharmacy benefit manager contract with a participating pharmacist or pharmacy shall not prohibit, restrict, or limit disclosure of information to the Commissioner, law enforcement, or State and federal government officials, provided that:

  (1) the recipient of the information represents that the recipient has the authority, to the extent provided by State or federal law, to maintain proprietary information as confidential; and

  (2) prior to disclosure of information designated as confidential, the pharmacist or pharmacy:

  (A) marks as confidential any document in which the information appears; and

  (B) requests confidential treatment for any oral communication of the information.

  (d) A pharmacy benefit manager shall not terminate a contract with or penalize a pharmacist or pharmacy due to the pharmacist or pharmacy:

  (1) disclosing information about pharmacy benefit manager practices, except for information determined to be a trade secret under State law or by the Commissioner, when disclosed in a manner other than in accordance with subsection (c) of this section; or

  (2) sharing any portion of the pharmacy benefit manager contract with the Commissioner pursuant to a complaint or query regarding the contract’s compliance with the provisions of this chapter.

  (e)(1) A pharmacy benefit manager shall not require a covered person purchasing a covered prescription drug to pay an amount greater than the lesser of:

  (A) the cost-sharing amount under the terms of the health benefit plan, as determined in accordance with subdivision (2) of this subsection (e);

  (B) the maximum allowable cost for the drug; or

  (C) the amount the covered person would pay for the drug, after application of any known discounts, if the covered person were paying the cash price.

  (2)(A) A pharmacy benefit manager shall attribute any amount paid by or on behalf of a covered person under subdivision (1) of this subsection (e), including any third-party payment, financial assistance, discount, coupon, or any other reduction in out-of-pocket expenses made by or on behalf of a covered person for prescription drugs, toward:

  (i) the out-of-pocket limits for prescription drug costs under 8 V.S.A. § 4089i;

  (ii) the covered person’s deductible, if any; and

  (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 person’s health benefit plan.

  (B) The provisions of subdivision (A) of this subdivision (2) 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 section 4601 of this title; or

  (ii) for which there is a generic drug or interchangeable biological product, as those terms are defined in section 4601 of this title, 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.

  (C) The provisions of subdivision (A) of this subdivision (2) 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.

  (f) A pharmacy benefit manager shall not conduct or participate in spread pricing in this State, which means that a pharmacy benefit manager must ensure that the total amount required to be paid by a health benefit plan and a covered person for a prescription drug covered under the plan does not exceed the amount paid to the pharmacy for dispensing the drug. (Added 2023, No. 127 (Adj. Sess.), § 1, eff. July 1, 2024.)