§1020.53. Physician-administered drugs; access; payment

            A.(1) A health insurance issuer, pharmacy benefit manager, or their agent shall not refuse to authorize, approve, or pay a participating provider for providing covered physician-administered drugs and related services to covered persons. A health insurance issuer shall not condition, deny, restrict, refuse to authorize or approve, or reduce payment to a participating provider for a physician-administered drug when all criteria for medical necessity are met, because the participating provider obtains physician-administered drugs from a pharmacy that is not a participating provider in the health insurance issuer's network. The drug supplied shall meet the supply chain security controls and chain of distribution set by the federal Drug Supply Chain Security Act, Pub. L. 113-54, as amended. The payment shall be at the rate set forth in the health insurance issuer's agreement with the participating provider applicable to such drugs, or if no such rate is included in the agreement, then at the wholesale acquisition cost. A health insurance issuer, pharmacy benefit manager, or their agent, shall not require a covered person to pay an additional fee, or any other increased cost-sharing amount in addition to applicable cost-sharing amounts payable by the covered person as designated within the benefit plan to obtain the physician-administered drug when provided by a participating provider. However, nothing in this Subpart shall prohibit a health insurance issuer or its agent from establishing differing copayments or other cost-sharing amounts within the benefit plan for covered persons who acquire physician-administered drugs from other providers. Nothing in this Subpart shall prohibit a health insurance issuer or its agent from refusing to authorize or approve, or from denying coverage of a physician-administered drug based upon failure to satisfy medical necessity criteria. For purposes of this Section, the location of receiving the physician-administered drug shall not be included in the medical necessity criteria.

            (2) Nothing in this Section shall prohibit a health insurance issuer from establishing specialty care centers of excellence based on nationally established, objective quality measures, to be utilized by covered persons focused on specific drugs or types of drugs to impact the safety, quality, affordability, and expertise of treatment.

            B. The commission of any act prohibited by this Subpart shall be considered an unfair method of competition and unfair practice or act which shall subject the violator to any and all actions, including investigative demands, private actions, remedies, and penalties, provided for in the Unfair Trade Practices and Consumer Protection Law.

            C. Any provision of a contract that is contrary to any provision of this Subpart shall be null, void, and unenforceable in this state.

            Acts 2021, No. 50, §1, eff. June 1, 2021.