KRS 304.17A-597: Prohibition against certain actions of administrator of pharmacy

benefits against pharmacy -- Right of pharmacist to provide information about

lower cost alternatives to insured.

To the extent permitted under federal law and except as provided in KRS 304.17A-595:

(1) With respect to the provision of pharmacy or pharmacist services under a health

plan, an insurer, a pharmacy benefit manager, or any other administrator of

pharmacy benefits:

(a) Shall not:

1. a. Require or incentivize a n insured to use a mail -order

pharmaceutical distributor, including a mail-order pharmacy.

b. Conduct prohibited under this subparagraph includes but is not

limited to imposing any cost-sharing requirement, fee, drug supply

limitation, or other condition r elating to pharmacy or pharmacist

services received from a retail pharmacy that is greater, or more

restrictive, than what would otherwise be imposed if the insured

used a mail -order pharmaceutical distributor, including a mail -

order pharmacy;

2. Prohibit a pharmacy or pharmacist from, or impose a penalty on a

pharmacy or pharmacist for, the following:

a. Selling a lower cost alternative to an insured, if one is available; or

b. Providing information to an insured un der subsection (2) of this

section;

3. Discriminate against any pharmacy or pharmacist that is:

a. Located within the geographic coverage area of the health plan;

and

b. Willing to agree to, or accept, reasonable terms and conditions

established for partic ipation in the insurer's, pharmacy benefit

manager's, other administrator's, or health plan's network;

4. Impose limits, including quantity limits or refill frequency limits, on an

insured's access to medication from a pharmacy that are more restrictive

than those existing for a pharmacy affiliate;

5. a. Require or incentivize an insured to receive pharmacy or

pharmacist services from a pharmacy affiliate.

b. Conduct prohibited under this subparagraph includes but is not

limited to:

i. Requiring or incentiv izing an insured to obtain a specialty

drug from a pharmacy affiliate;

ii. Charging less cost sharing to insureds that use pharmacy

affiliates than what is charged to insureds that use

nonaffiliated pharmacies; and

iii. Providing any incentives for insured s that use pharmacy

affiliates that are not provided for insureds that use

nonaffiliated pharmacies.

c. This subparagraph shall not be construed to prohibit:

i. Communications to insureds regarding networks and prices

if the communication is accurate and i ncludes information

about all eligible nonaffiliated pharmacies; or

ii. Requiring an insured to utilize a network that may include

pharmacy affiliates in order to receive coverage under the

plan, or providing financial incentives for utilizing that

network, if the insurer, pharmacy benefit manager, or other

administrator complies with this section and KRS 304.17A -

593; or

6. a. Interfere with an insured's right to choose the insured's network

pharmacy of choice.

b. For purposes of this subparagraph, interfer ing includes inducing,

steering, offering financial or other incentives, and imposing a

penalty, including but not limited to:

i. Promoting one (1) participating pharmacy over another;

ii. Offering a monetary advantage;

iii. Charging higher cost sharing; and

iv. Reducing an insured's allowable reimbursement for

pharmacy or pharmacist services; and

(b) Shall:

1. Provide equal access and incentives to all pharmacies within the

insurer's, pharmacy benefit manager's, other administrator's, or health

plan's network; and

2. Offer all pharmacies located in the health plan's geographic coverage

area eligibility to participate in the insurer's, pharmacy benefit

manager's, other administrator's, or health plan's network under identical

reimbursement terms for the prov ision of pharmacy or pharmacist

services; and

(2) A pharmacist shall have the right to provide an insured information regarding lower

cost alternatives to assist the insured in making informed decisions.