Statutes, codes, and regulations
Delaware Administrative Code
Title 18 - InsuranceHealth Insurance Specific Provisions
Registration and Regulation of Pharmacy Benefits Managers
Section 1411-10.0 - Network Adequacy Annual Reporting Requirements

18 Del. Admin. Code § 1411-10.0

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Current through Register Vol. 28, No. 5, November 1, 2024
Section 1411-10.0 - Network Adequacy Annual Reporting Requirements
10.1 Annually, no later than May 1, a pharmacy benefits manager shall submit to the Department a pharmacy benefits manager network adequacy report describing the pharmacy benefits manager network and the pharmacy benefits manager network's accessibility in this State, subject to the following:
10.1.1 The report is to address network adequacy in terms of patient access to physical pharmacy locations. The report may include a notation that mail-order pharmacy services are available, if applicable, but the report should not include mail-order pharmacies in calculations used to demonstrate the PBM's network adequacy.
10.2 The PBM's network adequacy report shall include at a minimum:
10.2.1 A hotspot map that shows density of network pharmacies;
10.2.2 A list identifying the number of lives within 5 miles, 10 miles, and 15 miles of a network pharmacy;
10.2.3 The percentage of covered individuals residing in urban, suburban, and rural service areas and their proximity to network retail pharmacies as follows:
10.2.3.1 The percentage of covered individuals residing in an urban service area who live within 2 miles of a retail pharmacy participating in the PBM's retail pharmacy network;
10.2.3.2 The percentage of covered individuals residing in an urban service area who live within 5 miles of a retail pharmacy designated as a preferred participating pharmacy in the PBM's retail pharmacy network;
10.2.3.3 The percentage of covered individuals residing in a suburban service area who live within 5 miles of a retail pharmacy participating in the PBM's retail pharmacy network;
10.2.3.4 The percentage of covered individuals residing in a suburban service area who live within 7 miles of a retain pharmacy designated as a preferred participating pharmacy in the PBM's retail pharmacy network;
10.2.3.5 The percentage of covered individuals residing in a rural service area who live within 15 miles of a retail pharmacy participating in the PBM's retail pharmacy network; and
10.2.3.6 The percentage of covered individuals residing in a rural service area who live within 18 miles of a retail pharmacy designated as a preferred participating pharmacy in the PBM's retail pharmacy network;
10.2.4 A description of how network adequacy is monitored to ensure a reasonably adequate and accessible network;
10.2.5 The percentage change in the number of pharmacies in the pharmacy network from the previous year; and
10.2.6 Any other information that the PBM may wish to provide to demonstrate network adequacy.

18 Del. Admin. Code § 1411-10.0

26 DE Reg. 594 (1/1/2023) (Final)