Missouri § 354.535 - Pharmacist, emergency situation, may take an assignment of enrollee's right to reimbursement — health maintenance organizations shall only contract with entities licensed by the board of pharmacy — requirements for drug prescriptions, exceptions.

§ 354.535. Pharmacist, emergency situation, may take an assignment of enrollee's right to reimbursement — health maintenance organizations shall only contract with entities licensed by the board of pharmacy — requirements for drug prescriptions, exceptions.

1.  If a pharmacy, operated by or contracted with by a health maintenance organization, is closed or is unable to provide health care services to an enrollee in an emergency, a pharmacist may take an assignment of such enrollee's right to reimbursement, if the policy or contract provides for such reimbursement, for those goods or services provided to an enrollee of a health maintenance organization.  No health maintenance organization shall refuse to pay the pharmacist any payment due the enrollee under the terms of the policy or contract.

2.  No health maintenance organization, conducting business in the state of Missouri, shall contract with a pharmacy, pharmacy distributor or wholesale drug distributor, nonresident or otherwise, unless such pharmacy or distributor has been granted a permit or license from the Missouri board of pharmacy to operate in this state.

3.  Every health maintenance organization shall apply the same coinsurance, co-payment and deductible factors to all drug prescriptions filled by a pharmacy provider who participates in the health maintenance organization's network if the provider meets the contract's explicit product cost determination.  If any such contract is rejected by any pharmacy provider, the health maintenance organization may offer other contracts necessary to comply with any network adequacy provisions of this act^*.  However, nothing in this section shall be construed to prohibit the health maintenance organization from applying different coinsurance, co-payment and deductible factors between generic and brand name drugs.

4.  Health maintenance organizations shall not set a limit on the quantity of drugs which an enrollee may obtain at any one time with a prescription, unless such limit is applied uniformly to all pharmacy providers in the health maintenance organization's network.

5.  Health maintenance organizations shall not insist or mandate any physician or other licensed health care practitioner to change an enrollee's maintenance drug unless the provider and enrollee agree to such change.  For the purposes of this provision, a maintenance drug shall mean a drug prescribed by a practitioner who is licensed to prescribe drugs, used to treat a medical condition for a period greater than thirty days.  Violations of this provision shall be subject to the penalties provided in section 354.444.  Notwithstanding other provisions of law to the contrary, health maintenance organizations that change an enrollee's maintenance drug without the consent of the provider and enrollee shall be liable for any damages resulting from such change.  Nothing in this subsection, however, shall apply to the dispensing of generically equivalent products for prescribed brand name maintenance drugs as set forth in section 338.056.

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(L. 1983 H.B. 127, A.L. 1997 H.B. 335, A.L. 1998 H.B. 1302)

*"This act" in 1997 referred to H.B. 335, 1997, which contained numerous sections.  "This act" now also includes H.B. 1302, 1998. Consult Disposition of Sections tables for both years for definitive listings.

(2000) Section is not preempted by Employee Retirement Income Security Act (ERISA).  Express Scripts, Inc. v. Wenzel, 102 F.Supp.2d 1135 (W.D.Mo.).

(2001) Section falls within savings clause of Employee Retirement Income Security Act (ERISA) as a regulation of insurance. Express Scripts, Inc. v. Wenzel, 262 F.3d 829 (8th Cir.).

---- end of effective  28 Aug 1998 ----

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