The Vermont Statutes Online

Title 18 : Health

Chapter 221 : Health Care Administration

Subchapter 009 : Pharmacy Benefit Managers

• § 9473. Pharmacy benefit managers; required practices with respect to pharmacies

  (a) Within 14 calendar days following receipt of a pharmacy claim, a pharmacy benefit manager or other entity paying pharmacy claims shall do one of the following:

  (1) Pay or reimburse the claim.

  (2) Notify the pharmacy in writing that the claim is contested or denied. The notice shall include specific reasons supporting the contest or denial and a description of any additional information required for the pharmacy benefit manager or other payer to determine liability for the claim.

  (b) 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.

  (c) A pharmacy benefit manager or other entity paying pharmacy claims shall not:

  (1) require a pharmacy to pass through any portion of the insured’s co- payment , or patient responsibility, to the pharmacy benefit manager or other payer;

  (2) prohibit a pharmacy or pharmacist from discussing information regarding the total cost for pharmacist services for a prescription drug;

  (3) prohibit or penalize a pharmacy or pharmacist for providing information to an insured regarding the insured’s cost-sharing amount for a prescription drug; or

  (4) prohibit or penalize a pharmacy or pharmacist for the pharmacist or other pharmacy employee disclosing to an insured the cash price for a prescription drug or selling a lower cost drug to the insured if one is available.

  (d) 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.

  (e) 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 (d) 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.

  (f) For each drug for which a pharmacy benefit manager establishes a maximum allowable cost in order to determine the reimbursement rate, the pharmacy benefit manager shall do all of the following:

  (1) Make available, in a format that is readily accessible and understandable by a pharmacist, the actual maximum allowable cost for each drug and the source used to determine the maximum allowable cost, which shall not be dependent upon individual beneficiary identification or benefit stage.

  (2) Update the maximum allowable cost at least once every seven calendar days. In order to be subject to maximum allowable cost, a drug must be widely available for purchase by all pharmacies in the State, without limitations, from national or regional wholesalers and must not be obsolete or temporarily unavailable.

  (3) Establish or maintain a reasonable administrative appeals process to allow a dispensing pharmacy provider to contest a listed maximum allowable cost.

  (4)(A) Respond in writing to any appealing pharmacy provider within 10 calendar days after receipt of an appeal, provided that, except as provided in subdivision (B) of this subdivision (4), a dispensing pharmacy provider shall file any appeal within 10 calendar days from the date its claim for reimbursement is adjudicated.

  (B) A pharmacy benefit manager shall allow a dispensing pharmacy provider to appeal after the 10-calendar-day appeal period set forth in subdivision (A) of this subdivision (4) if the prescription claim is subject to an audit initiated by the pharmacy benefit manager or its auditing agent.

  (5) For a denied appeal, provide the reason for the denial and identify the national drug code and a Vermont-licensed wholesaler of an equivalent drug product that may be purchased by contracted pharmacies at or below the maximum allowable cost.

  (6) For an appeal in which the appealing pharmacy is successful:

  (A) make the change in the maximum allowable cost within 30 business days after the redetermination; and

  (B) allow the appealing pharmacy or pharmacist to reverse and rebill the claim in question.

  (g) A pharmacy benefit manager shall not:

  (1) require a claim for a drug to include a modifier or supplemental transmission, or both, to indicate that the drug is a 340B drug unless the claim is for payment, directly or indirectly, by Medicaid; or

  (2) restrict access to a pharmacy network or adjust reimbursement rates based on a pharmacy’s participation in a 340B contract pharmacy arrangement.

  (h)(1) A pharmacy benefit manager or other third party that reimburses a 340B covered entity for drugs that are subject to an agreement under 42 U.S.C. § 256b through the 340B drug pricing program shall not reimburse the 340B covered entity for pharmacy-dispensed drugs at a rate lower than that paid for the same drug to pharmacies that are not 340B covered entities, and the pharmacy benefit manager shall not assess any fee, charge-back, or other adjustment on the 340B covered entity on the basis that the covered entity participates in the 340B program as set forth in 42 U.S.C. § 256b.

  (2) With respect to a patient who is eligible to receive drugs that are subject to an agreement under 42 U.S.C. § 256b through the 340B drug pricing program, a pharmacy benefit manager or other third party that makes payment for the drugs shall not discriminate against a 340B covered entity in a manner that prevents or interferes with the patient’s choice to receive the drugs from the 340B covered entity.

  (i) A pharmacy benefit manager shall not reimburse a pharmacy or pharmacist in this State an amount less than the amount the pharmacy benefit manager reimburses a pharmacy benefit manager affiliate for providing the same pharmacist services.

  (j) A pharmacy benefit manager shall not restrict, limit, or impose requirements on a licensed pharmacy in excess of those set forth by the Vermont Board of Pharmacy or by other State or federal law, nor shall it withhold reimbursement for services on the basis of noncompliance with participation requirements.

  (k) A pharmacy benefit manager shall provide notice to all participating pharmacies prior to changing its drug formulary. (Added 2013, No. 144 (Adj. Sess.), § 14; amended 2015, No. 54, § 3, eff. June 5, 2015; 2017, No. 193 (Adj. Sess.), § 11; 2021, No. 74, § E.227.1; 2021, No. 131 (Adj. Sess.), § 2, eff. January 1, 2023 and § 7, eff. May 24, 2022; 2023, No. 51, § 6, eff. July 1, 2023.)