Current through Register Vol. 28, No. 9, March 1, 2025
12.1 Unless
approved in advance by the Commissioner as provided in this Section
12.0, no PBM may do either of the
following:
12.1.1 Charge a pharmacist or
pharmacy a fee related to the adjudication of a claim, including a fee for any
of the following:
12.1.1.1 The receipt and
processing of a pharmacy claim;
12.1.1.2 The development or management of
claims processing services in a pharmacy benefits manager network; or
12.1.1.3 Participation in a pharmacy benefits
manager network; or
12.1.2 Require a pharmacy accreditation
standard or certification requirement that is inconsistent with, more stringent
than, or in addition to any requirements of the Board of
Pharmacy.
12.2 To seek
Commissioner approval of a fee as required under subsection 12.1.1 of this
regulation, a PBM shall provide the following minimum information:
12.2.1 The name, registration number and
contact information of the PBM;
12.2.2 The fee for which the PBM seeks
approval;
12.2.3 A statement
regarding how the fee is to be charged, the need for the fee, and whether the
fee represents a new fee, or an increase or decrease in a previously-charged
fee;
12.2.4 A statement as to
whether the requested fee applies to all contracted pharmacies within its
complete network or a subset of contracted pharmacies. If the fee applies only
to a subset of contracted pharmacies and/or the amount of the fee varies among
contracted pharmacies, the statement should include the reason for the
differential treatment among contracted pharmacies;
12.2.5 The PBM's anticipated revenue from the
fee; and
12.2.6 Any other
information the PBM wants the Department to consider as justification for the
proposed fee.
12.3 To
seek Commissioner approval of a pharmacy accreditation standard or
certification requirement as required under subsection 12.1.2 of this
regulation, a PBM shall provide the following minimum information on a form
provided by the Department for such purposes:
12.3.1 The name, registration number and
contact information of the PBM;
12.3.2 The accreditation standard or
certification requirement sought to be implemented;
12.3.3 A statement of how the accreditation
standard or certification requirement deviates from the requirements of the
Board of Pharmacy;
12.3.4 Detailed
justification for the necessity of an accreditation standard or certification
requirement that is inconsistent with, more stringent than, or in addition to
the requirements of the Board of Pharmacy, including the risk it is intended to
mitigate and why the Board of Pharmacy standards are not sufficient for those
purposes;
12.3.5 A statement
whether the accreditation standard or certification requirement applies to all
contracted pharmacies or a subset of contracted pharmacies. If the standard or
requirement applies only to a subset of contracted pharmacies, the statement
should include the reason for the differential treatment among contracted
pharmacies;
12.3.6 A statement
describing how application of the accreditation standard or certification
requirement may impact patient access to pharmacy services or the PBM's
network;
12.4 Upon
receipt by the Department of a submission pursuant to subsection 12.3 of this
regulation, the Department shall forward a copy of the submission to the
Executive Director of the Board of Pharmacy to be placed on the agenda for the
Board of Pharmacy's next available public meeting.
12.4.1 The PBM shall supplement its filing
under subsection 12.3 of this regulation with any additional information
requested by either the Department or the Board of Pharmacy.
12.4.2 Following consideration of the
submission by the Board of Pharmacy, the Department shall take under advisement
any recommendation provided or position taken by the Board of Pharmacy
regarding the additional accreditation standard or certification requirement
when rendering a final decision on the PBM's sub-mission under subsection 12.3
of this regulation.
