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Pennsylvania Statutes Title 40 P.S. Insurance § 4525. Contract provisions

Current as of January 01, 2025 | Updated by Findlaw Staff

<Section 14(1) of Act 2024, July 17, P.L. 852, No. 77, provides that the addition of Chapter 6 by that Act shall apply to contracts issued, renewed or amended after Oct. 15, 2024. See, also, additional applicability provisions in § 14(2) of such Act.>

(a) General rule.--A PBM registered with the department and conducting business on behalf of a health insurer client in this Commonwealth may not:

(1) Reimburse a retail pharmacy an amount less than the amount that the PBM reimburses a PBM-affiliated retail pharmacy located in this Commonwealth for providing the same pharmacist services.

(2) Reimburse a federally qualified health center, health care facility or other entity participating in the program under section 340(b) of the Public Health Service Act (58 Stat. 682, 42 U.S.C. § 256(b)) an amount lesser than similar entities not participating in the program.

(3) Authorize the PBM to unilaterally alter the terms of a participation contract beyond the terms and conditions of the original contract agreed to by a PSAO or pharmacy with a PBM beyond the terms and conditions of the original contract agreed to by the pharmacy or PSAO with a PBM.

(4) Designate a prescription drug as a specialty drug or require a prescription drug to be dispensed exclusively at a specialty pharmacy unless it meets the criteria of a specialty drug under section 103.  1

(b) Rebates.--Beginning on the effective date of this section, a PBM shall pass through to the health benefit plan no less than 95% of any prescription drug manufacturer rebate obtained by the PBM on behalf of a health insurer client if the health benefit plan delegates negotiation of the rebate to the PBM.

(c) Contract information.--PBM contracts shall provide information to a pharmacist, pharmacy or PSAO pertaining to the schedule and total for any fee charged by the PBM for participation in the PBM's network.

1 40 P.S. § 4503.
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Cite this article: FindLaw.com - Pennsylvania Statutes Title 40 P.S. Insurance § 4525. Contract provisions - last updated January 01, 2025 | https://codes.findlaw.com/pa/title-40-ps-insurance/pa-st-sect-40-4525/

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