§33-51-1. Short Title
This article may be cited and known as the Pharmacy Audit Integrity Act.
§33-51-10. Commissioner Required to Propose Rules
The Insurance Commissioner shall propose rules for legislative approval in accordance with 29A-3-1 et seq. of this code that are necessary to effectuate the provisions of this article.
§33-51-11. Freedom of Consumer Choice for Pharmacy
(a) A pharmacy benefits manager, may not: (1) Prohibit or limit any covered individual from selecting a pharmacy or pharmacist of his or her choice who has agreed to participate in the health benefit plan according to the terms offered by the health benefit plan;
§33-51-12. Reporting Requirements
(a) A pharmacy benefits manager shall report to the commissioner on an annual basis, or more often as the commissioner deems necessary, for each health plan or covered entity the following information: (1) The aggregate amount of rebates received by the pharmacy benefits manager;
§33-51-13. Effective Date
Notwithstanding any other effective date to the contrary, the amendments to this article enacted during the 2022 regular legislative session shall apply to all policies, contracts, plans, or agreements subject to this section that are delivered, executed, amended, adjusted, or renewed on or after January 1, 2023.
§33-51-2. Scope
This article covers any audit of the records of a pharmacy conducted by a managed care company, third-party payer, pharmacy benefits manager or an entity that represents a covered entity, or health benefit plan, the registration of auditing entities, and the licensure and regulation of pharmacy benefits managers.
§33-51-3. Definitions
For purposes of this article: “340B entity” means an entity participating in the federal 340B drug discount program, as described in 42 U.S.C. 256b, including its pharmacy or pharmacies, or any pharmacy or pharmacies, contracted with the participating entity to dispense drugs purchased through such program. “Affiliate” means a pharmacy, pharmacist, or pharmacy technician which, […]
§33-51-4. Procedures for Conducting Pharmacy Audits
(a) An entity conducting a pharmacy audit under this article shall conform to the following rules: (1) Except as otherwise provided by federal or state law, an auditing entity conducting a pharmacy audit may have access to a pharmacys previous audit report only if the report was prepared by that auditing entity.
§33-51-5. Appeals Process
A pharmacy may appeal a final audit report in accordance with the procedures established by the entity conducting the pharmacy audit.
§33-51-6. Limitations
(a) The provisions of this article do not apply to an investigative audit of pharmacy records when: (1) Fraud, waste, abuse or other intentional misconduct is indicated by physical review or review of claims data or statements; or
§33-51-7. Pharmacy Benefits Manager and Auditing Entity Registration
(a) Prior to conducting business in the State of West Virginia, except as provided in subsection (d) of this section, an auditing entity shall register with the Insurance Commissioner. The commissioner shall make an application form available on its publicly accessible Internet website that includes a request for the following information: (1) The identity, address, […]
§33-51-8. Licensure of Pharmacy Benefit Managers
(a) A person or organization may not establish or operate as a pharmacy benefits manager in the state of West Virginia without first obtaining a license from the Insurance Commissioner pursuant to this section: Provided, That a pharmacy benefit manager registered pursuant to 33-51-7 of this code may continue to do business in the state […]
§33-51-9. Regulation of Pharmacy Benefit Managers
(a) A pharmacy, a pharmacist, and a pharmacy technician shall have the right to provide a covered individual with information related to lower cost alternatives and cost share for the covered individual to assist health care consumers in making informed decisions. Neither a pharmacy, a pharmacist, nor a pharmacy technician may be penalized by a […]