The Vermont Statutes Online
Title 18 : Health
Chapter 221 : HEALTH CARE ADMINISTRATION
Subchapter 002 : CLAIMS PROCESSING AND CONTRACT STANDARDS(Cite as: 18 V.S.A. § 9421)
§ 9421. Pharmacy benefit management; registration; insurer audit of pharmacy benefit manager activities
(a) A pharmacy benefit manager shall not do business in this State without first registering with the Commissioner on a form and in a manner prescribed by the Commissioner.
(b) In accordance with rules adopted by the Commissioner, pharmacy benefit managers operating in the State of Vermont and proposing to contract for the provision of pharmacy benefit management shall notify health insurers when the pharmacy benefit manager provides a quotation that a quotation for an administrative-services-only contract with full pass through of negotiated prices, rebates, and other such financial benefits that would identify to the health insurer external sources of revenue and profit is generally available and whether the pharmacy benefit manager offers that type of arrangement. Quotations for an administrative-services-only contract shall include a reasonable fee payable by the health insurer that represents a competitive pharmacy benefit profit. This subsection shall not be interpreted to require a pharmacy benefit manager to offer an administrative-services-only contract.
(c) In order to enable periodic verification of pricing arrangements in administrative-services-only contracts, pharmacy benefit managers shall allow access, in accordance with rules adopted by the Commissioner, by the health insurer who is a party to the administrative-services-only contract to financial and contractual information necessary to conduct a complete and independent audit designed to verify the following:
(1) full pass through of negotiated drug prices and fees associated with all drugs dispensed to beneficiaries of the health plan in both retail and mail order settings or resulting from any of the pharmacy benefit management functions defined in the contract;
(2) full pass through of all financial remuneration associated with all drugs dispensed to beneficiaries of the health plan in both retail and mail order settings or resulting from any of the pharmacy benefit management functions defined in the contract; and
(3) any other verifications relating to the pricing arrangements and activities of the pharmacy benefit manager required by the contract if required by the Commissioner.
(d) The reasonable expenses of the Department of Financial Regulation in administering the provisions of this section may be charged to pharmacy benefit managers in the manner provided for in 8 V.S.A. § 18. These expenses shall be allocated in proportion to the lives of Vermonters covered by each pharmacy benefit manager as reported annually to the Commissioner in a manner and form prescribed by the Commissioner. The Department of Financial Regulation shall not charge its expenses to the pharmacy benefit manager contracting with the Department of Vermont Health Access if the Department of Vermont Health Access notifies the Department of Financial Regulation of the conditions contained in its contract with a pharmacy benefit manager.
(e) The Commissioner may adopt such rules as are necessary or desirable in carrying out the purposes of this section. The rules also shall ensure that proprietary information is kept confidential and not disclosed by a health insurer.
[Subsection (f) redesignated as subsection (g) effective January 1, 2023; for subsection (f) effective January 1, 2023 see below.]
(f) As used in this section:
(1) “Health insurer” shall have the same meaning as in subdivision 9471(2) of this title.
(2) “Health plan” shall have the same meaning as in subdivision 9471(3) of this title.
(3) “Pharmacy benefit management” shall have the same meaning as in subdivision 9471(4) of this title.
(4) “Pharmacy benefit manager” shall have the same meaning as in subdivision 9471(5) of this title.
[Subsection (f) effective January 1, 2023; for subsection (f) effective until January 1, 2023 see above.]
(f) The Department of Financial Regulation shall monitor the cost impacts on Vermont consumers of pharmacy benefit manager regulation pursuant to this section, subchapter 9 of this chapter, and 8 V.S.A. chapter 107 and shall recommend appropriate modifications to the laws as needed to promote health care affordability in this State. (Added 2007, No. 80, § 9; amended 2009, No. 156 (Adj. Sess.), § I.29; 2011, No. 150 (Adj. Sess.), § 3; 2017, No. 113 (Adj. Sess.), § 109; 2021, No. 131 (Adj. Sess.), § 1a, eff. January 1, 2023.)