Sec. 21.27.951. Patient access to clinician-administered drugs.

368 words·~2 min read·/ak/title-21/chapter-27/21-27-951

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

(a)An insurer or its pharmacy benefits manager may not

(1)refuse to authorize, approve, or pay a provider for providing covered clinician-administered drugs and related services to a covered person if the provider has agreed to participate in the insurer's health care insurance policy according to the terms offered by the insurer or its pharmacy benefits manager;

(2)if the criteria for medical necessity are met, condition, deny, restrict, or refuse to authorize or approve a provider for a clinician-administered drug because the provider obtained the clinician-administered drug from a pharmacy that is not a network pharmacy in the insurer's or its pharmacy benefits manager's network;

(3)require a pharmacy to dispense a clinician-administered drug directly to a covered person or agent of the insured with the intention that the covered person or the agent of the insured will transport the medication to a provider for administration;

(4)require or encourage the dispensing of a clinician-administered drug to a covered person in a manner that is inconsistent with the supply chain security controls and chain of distribution set by 21 U.S.C. 360eee — 360eee-4 (Drug Supply Chain Security Act);

(5)require that a clinician-administered drug be dispensed or administered to a covered person in the residence of the covered person or require use of an infusion site external to the office, department, or clinic of the provider of the covered person; nothing in this paragraph prohibits the insurer or its pharmacy benefits manager, or an agent of the insurer or its pharmacy benefits manager, from offering the use of a home infusion pharmacy or external infusion site.

(b)If a health insurance policy provides in-network and out-of-network benefits and there is not an in-network health care provider or health care facility within a 50-mile radius of the primary residence of a covered person, the health insurance policy must provide coverage to the covered person for clinician-administered drugs at the minimum in-network benefit level.

(c)In this section, “clinician-administered drug” means a drug, other than a vaccine, that requires administration by a provider and that the United States Food and Drug Administration or the drug's manufacturer has not approved for self-administration.