TITLE 27
Insurance
CHAPTER 27-29.1
Pharmacy Freedom of Choice Fair Competition and Practices
SECTION 27-29.1-5
§ 27-29.1-5 Participation of independent
community pharmacies.
(a) Any pharmacies licensed in the state of Rhode Island that are not owned or
controlled, directly or indirectly by an entity that owns pharmacies licensed
in two (2) or more jurisdictions other than Rhode Island, which are not
participating in an insurer's restricted pharmacy network contract shall
nevertheless have the right to provide prescription drug services to the
insurer's insureds and be paid by the insurer as if the pharmacy were
participating in the insurer's restricted pharmacy network, provided that such
non-network independent pharmacies agree:
(1) To accept as the insurer's payments in full the price
required of pharmacies in the insurer's restricted pharmacy network;
(2) To bill to the insured up to and not in excess of any
copayment, coinsurance, deductible, other amount required of an insured by the
insurer, or for other uncovered services;
(3) To be reimbursed on the same methodological basis,
including, but not limited to, capitation or other risk-sharing methodology, as
required of pharmacies, in the insurer's restricted pharmacy network;
(4) To participate in the insurer's utilization review and
quality assurance programs, including utilization and drug management reports
as required of pharmacies in the carrier's restricted pharmacy network;
(5) To provide computerized online eligibility determinations
and claims submissions as required of pharmacies in the insurer's restricted
pharmacy network;
(6) To participate in the insurer's satisfaction surveys and
complaint resolution programs for its insureds;
(7) To protect the insurer's proprietary information and an
insured's confidentiality and privacy;
(8) To abide by the insurer's performance standards with
respect to waiting times, fill rates and inventory management, including
formulary restrictions;
(9) To comply with the insurer's claims audit provisions; and
(10) To certify, using audit results or accountant
statements, the fiscal soundness of the non-network pharmacy.
(b) An insurer may waive any of the aforementioned agreements
in arranging for the provision of pharmaceutical drug benefits to insureds
through a non-network pharmacy. An insurer shall not impose any agreements,
terms or conditions on any non-network independent community pharmacy, or on
any association of pharmacies, which are more restrictive than those required
of pharmacies in the insurer's restricted pharmacy network. The failure of a
non-network pharmacy to abide by the aforementioned agreements may, at the
option of the insurer, serve as the basis for cancellation of the non-network
pharmacy's participation.
History of Section.
(P.L. 2004, ch. 363, § 2; P.L. 2004, ch. 368, § 2; P.L. 2004, ch.
602, § 2; P.L. 2008, ch. 475, § 89.)