W. Va. Code R. § 114-99-6

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-99-6 - Network Adequacy and Reporting Requirements

6.1. Network adequacy and prohibition against required use of mail-order pharmacy.

6.1.1. A PBM shall maintain a reasonably adequate and accessible network for the provision of prescription drugs for a health benefit plan. The network shall provide for convenient patient access to pharmacies within a reasonable distance from a patient's residence. A network shall not be comprised only of mail-order benefits but must have a mix of mail-order benefits and physical stores in this state.

6.1.1.a. Pursuant to W. Va. Code §§ 33-16-3q, 33-24-7h, 33-25-8f and 33-25A-8g, an insurer issuing a group accident and sickness policy, a hospital, medical, dental or health service corporation, a health care corporation, or a health maintenance organization may not require any covered individual to obtain prescription drugs from a mail-order pharmacy in order to obtain prescription drug benefits, and may not violate this prohibition by using an agent, contractor or administrator that requires the covered person to obtain prescription drugs from a mail-order pharmacy. An insurer, hospital, medical, dental or health service corporation, a health care corporation, or a health maintenance organization that violates W. Va. Code §§ 33-16-3q, 33-24-7h, 33-25-8f and 33-25A-8g through the use of a PBM may be subject to regulatory action as permitted under Chapter 33 of the West Virginia Code.

6.1.2. A PBM shall, upon licensure and upon further request by the Commissioner, provide a network report describing the PBM's network and the mix of mail-order to physical stores in this state and shall include a detailed description of any separate, sub-networks for specialty drugs. The detailed description should include a statement as to whether the PBM has restricted distribution of specialty drugs to mail-order specialty pharmacies or affiliate pharmacies, and if so, the reasons therefore, and further provide the names and addresses of any specialty pharmacies in the PBM's network that are not solely mail-order pharmacies or affiliate pharmacies and are located in West Virginia, or in an out-of-state county that is adjacent to West Virginia. This statement shall also include a list of all specialty drugs currently on restricted distribution to specialty pharmacies or affiliate pharmacies. Failure to provide a report may result in the suspension or revocation of a PBM's license by the Commissioner.

6.1.3. Health benefit plans using PBMs for administration of pharmacy management benefits shall, upon request, provide the Commissioner with the number of pharmacists, pharmacies and pharmacy services administration organizations that have either terminated their network participation with the health benefit plan or have had their network participation terminated by the health benefit plan.

6.1.4. A PBM using a leased network must ensure that the leased network is reasonably adequate and accessible as provided in subsection 6.1.1 of this rule and the PBM using the leased network must be able to provide the reports described in subsections 6.1.2 and 6.1.3 of this rule upon request by the Commissioner.

6.2. Annual Reports.

6.2.1. A PBM shall report to the Commissioner on or before March 1 of each year, or more often as the Commissioner deems necessary, for each health benefit plan the following information:

6.2.1.a. The aggregate amount of rebates received by the PBM;

6.2.1.b. The aggregate amount of rebates distributed to the health benefit plan;

6.2.1.c. The aggregate amount of rebates used at the point-of-sale to reduce a covered individual's defined cost sharing in accordance with section 5.14. of this rule;

6.2.1.d. The individual and aggregate amount paid by the health benefit plan to the PBM for pharmacist services itemized by pharmacy, by product, and by goods and services; and

6.2.1.e. The individual and aggregate amount a PBM paid for pharmacist services itemized by pharmacy, by product, and by goods and services.

6.2.2. In regard to a PBM that contracts with a health benefit plan, the PBM shall annually report in the aggregate to the Commissioner and to the health benefit plan the difference between the amount the PBM reimbursed a pharmacy and the amount the PBM charged the health benefit plan. The annual report required by this subsection may be referred to as the "spread pricing report" and shall be due on or before March 1 of each year.

6.2.3. A health benefit plan shall annually report to the Commissioner the aggregate amount of credits, rebates, discounts, or other such payments received by the health benefit plan from a PBM or drug manufacturer and disclose whether or not those credits, rebates, discounts or other such payments were passed on to reduce insurance premiums or rates. The Commissioner will use the information obtained in these reports when reviewing premium rates charged for individual and group accident and health insurance as set forth in W. Va. Code §§ 33-6-9(e), 33-24-6(c) and 33-25A-8. The annual report required by this subsection shall be due on or before March 1 of each year.

6.3. Quarterly Report.

6.3.1. A PBM shall produce a quarterly report to the Commissioner of:

6.3.1.a. All drugs appearing on the national average drug acquisition cost list reimbursed 10% and below the national average drug acquisition cost; and

6.3.1.b. All drugs appearing on the national average drug acquisition cost list reimbursed 10% and above the national average drug acquisition cost.

6.3.2. For each drug listed in the quarterly report, a PBM shall include:

6.3.2.a. The month the drug was dispensed;

6.3.2.b. The quantity of the drug dispensed;

6.3.2.c. The amount the pharmacy was reimbursed;

6.3.2.d. Whether the dispensing pharmacy was an affiliate of the PBM;

6.3.2.e. Whether the drug was dispensed pursuant to a government health benefit plan; and

6.3.2.f. The average national drug acquisition cost for the month the drug was dispensed.

6.3.3. The quarterly report shall exclude drugs dispensed pursuant to 42 U.S.C. § 256b.

6.3.4. A copy of the quarterly report shall be published on the PBM's publicly available website for a period of at least 24 months.

6.3.5. The quarterly report is exempt from the confidentiality provisions of section 6.5 of this rule.

6.3.6. The quarterly report required by this section shall be filed on or before May 15, August 15, November 15 and March 1 of each year; the final quarterly report being submitted with the annual report(s) required in section 6.2 of this rule.

6.4. The reports required by this section shall be filed electronically by the PBM or health benefit plan via the portal made available on the Commissioner's website.

6.5. With the exception of the quarterly report noted in section 6.3 of this rule, the information and data submitted by a PBM, health benefit plan under this section shall be considered proprietary and confidential by law and privileged, exempt from disclosure pursuant to Chapter 29B of the West Virginia Code as a "trade secret", is not open to public inspection, is not subject to subpoena, is not subject to discovery or admissible in evidence in any criminal, private civil or administrative action and is not subject to production pursuant to court order. The Commissioner is authorized to use the documents, materials or other information in the furtherance of any regulatory or legal action brought as part of the Commissioner's official duties.

W. Va. Code R. § 114-99-6