House Journal: Page 959: Wednesday, April 2, 2003
32 payment made by the pharmacy benefits manager. Usual
33 and customary pricing is confidential and a pharmacy
34 benefits manager is prohibited from any other use or
35 disclosure of usual and customary pricing.
36 6. A pharmacy benefits manager shall not move a
37 plan to another payment network unless the pharmacy
38 benefits manager receives written consent from the
39 plan sponsor.
40 7. A pharmacy benefits manager shall not receive
41 or accept any rebate, kickback, or any special payment
42 or favor or advantage of any valuable consideration or
43 inducement for changing a patient's drug product
44 unless the change is specified in a written contract
45 that has been filed with the commissioner at least
46 thirty days prior to the execution of the contract.
47 8. A claim paid by a pharmacy benefits manager
48 shall not be retroactively denied or adjusted after
49 seven days from adjudication of the claim.
50 Acknowledgement of eligibility shall not be
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1 retroactively reversed. A pharmacy benefits manager
2 may retroactively deny or adjust a claim only if the
3 original claim was submitted fraudulently, the
4 original claim payment was incorrect because the
5 provider was previously paid for services rendered, or
6 the services were not rendered by the pharmacist.
7 9. A pharmacy benefits manager shall not terminate
8 a pharmacy from a network based on any of the
9 following:
10 a. The pharmacy expresses disagreement with the
11 pharmacy benefits manager's decision to deny or limit
12 benefits to an enrollee.
13 b. A pharmacist employed by the pharmacy discusses
14 with a current, former, or prospective enrollee any
15 aspect of the person's medical condition or treatment
16 alternatives whether or not the service is a covered
17 service.
18 c. A pharmacist employed by the pharmacy makes a
19 personal recommendation regarding selecting a pharmacy
20 benefits manager based on the pharmacist's personal
21 knowledge of the health needs of the individual.
22 d. The pharmacy protests or expresses disagreement
23 with a medical decision, medical policy, or medical
24 practice of a pharmacy benefits manager.
25 e. The pharmacy has in good faith communicated
26 with or advocated on behalf of one or more of the
27 pharmacy's current, former, or prospective enrollees
28 regarding the provisions, terms, or requirements of
29 the pharmacy benefits manager's health benefit plans
30 as they relate to the needs of the individual
© 2003 Cornell College and
League of Women Voters of Iowa
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