Section 304 – Claims practices.
Effective 5/12/2020 31A-46-304. Claims practices. (1) A pharmacy benefit manager shall permit a pharmacy to collect the amount of a customer’s cost share from any source. (2) A pharmacy benefit manager may not deny or reduce a reimbursement to a pharmacy or a pharmacist after the adjudication of the claim, unless: (a) the pharmacy or […]
Section 305 – Pharmacy reimbursement.
Effective 5/12/2020 31A-46-305. Pharmacy reimbursement. A pharmacy benefit manager shall reimburse a network pharmacy, in the aggregate, in an amount no less than the amount that the pharmacy benefit manager reimburses an affiliate of the pharmacy benefit manager in the same network, in the aggregate, for providing the same or equivalent pharmacy service. Enacted by […]
Section 306 – Mailing or delivering prescription drugs.
Effective 5/12/2020 31A-46-306. Mailing or delivering prescription drugs. A pharmacy benefit manager or an insurer may not, directly or indirectly: (1) prohibit an in-network retail pharmacy from: (a) mailing or delivering a prescription drug to an enrollee as an ancillary service of the in-network retail pharmacy; (b) charging a shipping or handling fee to an […]
Section 303 – Network provider contract provisions.
Effective 5/14/2019 31A-45-303. Network provider contract provisions. (1) Managed care organizations may provide for enrollees to receive services or reimbursement in accordance with this section. (2) (a) Subject to restrictions under this section, a managed care organization may enter into contracts with health care providers under which the health care providers agree to be a […]
Section 304 – Objective criteria for adding or terminating network providers — Termination of contracts — Review process.
Effective 1/1/2018 31A-45-304. Objective criteria for adding or terminating network providers — Termination of contracts — Review process. (1) (a) A managed care organization shall establish criteria for adding health care providers to a new or existing network provider panel. (b) Criteria under Subsection (1)(a) may include: (i) training, certification, and hospital privileges; (ii) number […]
Section 305 – Prohibition on certain age-based physician testing.
Effective 5/14/2019 31A-45-305. Prohibition on certain age-based physician testing. A managed care organization or other third party may not require for purposes of reimbursement that a physician, as defined in Section 58-67-102, take a cognitive test when the physician reaches a specified age, unless the test reflects the standards described in Subsections 58-67-302(5)(b)(i) through (x). […]
Section 401 – Court ordered coverage for minor children who reside outside the service area.
Effective 5/14/2019 31A-45-401. Court ordered coverage for minor children who reside outside the service area. (1) (a) The requirements of Subsection (2) apply to a managed care organization if the managed care organization: (i) restricts coverage for nonemergency services to services provided by contracted providers within the organization’s service area; and (ii) does not offer […]
Section 402 – Alcohol and drug dependency treatment.
Effective 1/1/2018 31A-45-402. Alcohol and drug dependency treatment. (1) A managed care organization offering a health benefit plan providing coverage for alcohol or drug dependency treatment may require an inpatient facility to be licensed by: (a) (i) the Department of Human Services, under Title 62A, Chapter 2, Licensure of Programs and Facilities; or (ii) the […]
Section 403 – Essential health benefits.
Effective 5/8/2018 31A-45-403. Essential health benefits. (1) The state designates the state’s own essential health benefits and does not accept a federal determination of the essential health benefits under the PPACA. (2) Subject to Subsections (3) and (4), the commissioner shall make rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, that […]
Section 501 – Access to health care providers.
Effective 5/5/2021 31A-45-501. Access to health care providers. (1) As used in this section: (a) “Class of health care provider” means a health care provider or a health care facility regulated by the state within the same professional, trade, occupational, or certification category established under Title 58, Occupations and Professions, or within the same facility […]