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§27-29.1-5  Participation of independent community pharmacies. –

Published: 2015

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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.)