Operating Requirements

Utah Code tit. 31A, ch. 31A-46, pt. 31A-46-P3

in effect

Utah Code § 31A-46-301 Reporting requirements.

31A-46-301. Reporting requirements. (1) Before April 1 of each year, a pharmacy benefit manager operating in the state shall report to the department, for the previous calendar year: (a) any insurer, pharmacy, or pharmacist in the state with which the pharmacy benefit manager had a contract; (b) the total value, in the aggregate, of all rebates and administrative fees that are attributable to enrollees of a contracting insurer; and (c) if applicable, the percentage of aggregate rebates that the pharmacy benefit manager retained under the pharmacy benefit manager's agreement to provide pharmacy benefits management services to a contracting insurer. (2) Records submitted to the commissioner under Subsections (1)(b) and (c) are a protected record under Title 63G, Chapter 2, Government Records Access and Management Act. (3) (a) The department shall publish the information provided by a pharmacy benefit manager under Subsection (1)(c) in the annual report described in Section 31A-2-201.2. (b) The department may not publish information submitted under Subsection (1)(b) or (c) in a manner that: (i) makes a specific submission from a contracting insurer or pharmacy benefit manager identifiable; or (ii) is likely to disclose information that is a trade secret as defined in Section 13-24-2. (c) At least 30 days before the day on which the department publishes the data, the department shall provide a pharmacy benefit manager that submitted data under Subsection (1)(b) or (c) with: (i) a general description of the data that will be published by the department; (ii) an opportunity to submit to the department, within a reasonable period of time and in a manner established by the department by rule made in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act: (A) any correction of errors, with supporting evidence and comments; and (B) information that demonstrates that the publication of the data will violate Subsection (3)(b), with supporting evidence and comments. Amended by Chapter 198, 2020 General Session

Utah Code § 31A-46-302 Direct or indirect remuneration by pharmacy benefit managers -- Disclosure of customer costs -- Limit on customer payment for prescription drugs.

31A-46-302. Direct or indirect remuneration by pharmacy benefit managers -- Disclosure of customer costs -- Limit on customer payment for prescription drugs. (1) If a pharmacy service entity engages in direct or indirect remuneration with a pharmacy, the pharmacy service entity shall make a reimbursement report available to the pharmacy upon the pharmacy's request. (2) For the reimbursement report described in Subsection (1), the pharmacy service entity shall: (a) include the adjusted compensation amount related to a claim and the reason for the adjusted compensation; and (b) provide the reimbursement report: (i) in accordance with the contract between the pharmacy and the pharmacy service entity; (ii) in an electronic format that is easily accessible; and (iii) within 120 days after the day on which the pharmacy benefit manager receives a report of a sale of a product or service by the pharmacy. (3) A pharmacy service entity shall, upon a pharmacy's request, provide the pharmacy with: (a) the reasons for any adjustments contained in a reimbursement report; and (b) an explanation of the reasons provided in Subsection (3)(a). (4) (a) A pharmacy benefit manager may not prohibit or penalize the disclosure by a pharmacist of: (i) an insured customer's cost share for a covered prescription drug or prescription device; (ii) the availability of any therapeutically equivalent alternative medications; or (iii) alternative methods of paying for the prescription medication or prescription device, including paying the cash price, that are less expensive than the cost share of the prescription drug. (b) Penalties that are prohibited under Subsection (4)(a) include increased utilization review, reduced payments, and other financial disincentives. (5) A pharmacy benefit manager may not require an insured customer to pay, for a covered prescription drug or prescription device, more than the lesser of: (a) the applicable cost share of the prescription drug or prescription device being dispensed; (b) the applicable allowable claim amount of the prescription drug or prescription device being dispensed; (c) the applicable pharmacy reimbursement of the prescription drug or prescription device being dispensed; or (d) the retail price of the prescription drug or prescription device without prescription drug coverage. (6) For a contract entered into or renewed on or after May 12, 2020, a pharmacy benefit manager may not engage in direct or indirect remuneration that results in a reduction in total compensation received by a pharmacy from the pharmacy benefit manager for the sale of a drug, device, or other product or service unless the pharmacy benefit manager provides the pharmacy with at least 30 days notice of the direct or indirect remuneration. Amended by Chapter 198, 2020 General Session, (Coordination Clause) Amended by Chapter 198, 2020 General Session Amended by Chapter 275, 2020 General Session

Utah Code § 31A-46-303 Insurer and pharmacy benefit management services -- Registration -- Maximum allowable cost -- Audit restrictions.

31A-46-303. Insurer and pharmacy benefit management services -- Registration -- Maximum allowable cost -- Audit restrictions. (1) An insurer and an insurer's pharmacy benefit manager is subject to the pharmacy audit provisions of Section 58-17b-622. (2) A pharmacy benefit manager shall not use maximum allowable cost as a basis for reimbursement to a pharmacy unless: (a) the drug is listed as "A" or "B" rated in the most recent version of the United States Food and Drug Administration's approved drug products with therapeutic equivalent evaluations, also known as the "Orange Book," or has an "NR" or "NA" rating or similar rating by a nationally recognized reference; and (b) the drug is: (i) generally available for purchase in this state from a national or regional wholesaler; and (ii) not obsolete. (3) The maximum allowable cost may be determined using comparable and current data on drug prices obtained from multiple nationally recognized, comprehensive data sources, including wholesalers, drug file vendors, and pharmaceutical manufacturers for drugs that are available for purchase by pharmacies in the state. (4) For every drug for which the pharmacy benefit manager uses maximum allowable cost to reimburse a contracted pharmacy, the pharmacy benefit manager shall: (a) make a list available to a network pharmacy upon request in a format that: (i) is electronic; (ii) is computer accessible and searchable; (iii) identifies all drugs for which maximum allowable costs have been established; and (iv) for each drug specifies: (A) the national drug code; and (B) the maximum allowable cost; (b) include in the contract with the pharmacy information identifying the national drug pricing compendia and other data sources used to obtain the drug price data; (c) review and make necessary adjustments to the maximum allowable cost, using the most recent data sources identified in Subsection (4)(b), at least once per week; (d) provide a process for the contracted pharmacy to appeal the maximum allowable cost in accordance with Subsection (5); and (e) include in each contract with a contracted pharmacy a process to obtain an update to the pharmacy product pricing files used to reimburse the pharmacy in a format that is readily available and accessible. (5) (a) The right to appeal in Subsection (4)(d) shall be: (i) limited to 21 days following the initial claim adjudication; and (ii) investigated and resolved by the pharmacy benefit manager within 14 business days. (b) A pharmacy benefit manager shall: (i) provide as part of the appeals process: (A) a dedicated telephone number, electronic mail address, and website for the purpose of submitting appeals; and (B) the ability for a pharmacy to submit an appeal directly to the pharmacy benefit manager or through the pharmacy's pharmacy services administrative organization; and (ii) allow a pharmacy to submit documentation in support of the pharmacy's appeal on paper or electronically. (c) If an appeal is denied, the pharmacy benefit manager shall provide the contracted pharmacy: (i) the reason for the denial; (ii) the identification of the national drug code of the drug that may be purchased by the pharmacy at a price at or below the price determined by the pharmacy benefit manager; and (iii) the specific basis upon which the pharmacy benefit manager can show that the drug is available for purchase at or below the maximum allowable cost. (d) If an appeal is upheld or the pharmacy benefit manager cannot show the drug is available for purchase at or below the maximum allowable cost for a similarly situated pharmacy as the pharmacy that submitted the appeal, the pharmacy benefit manager shall: (i) make an adjustment for the pharmacy that appealed; (ii) permit the dispensing pharmacy to reverse the claim and resubmit an adjusted claim without an additional charge; and (iii) consider additional action consistent with the outcome of the appeal. (6) The contract with each pharmacy shall contain a dispute resolution mechanism in the event either party breaches the terms or conditions of the contract. (7) This section does not apply to a pharmacy benefit manager when the pharmacy benefit manager is providing pharmacy benefit management services on behalf of the Medicaid program. Amended by Chapter 208, 2026 General Session

Utah Code § 31A-46-304 Claims practices.

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 pharmacist submitted the original claim fraudulently; (b) the original reimbursement was incorrect because: (i) the pharmacy or pharmacist had already been paid for the pharmacy service; or (ii) an unintentional error resulted in an incorrect reimbursement; or (c) the pharmacy service was not rendered by the pharmacy or pharmacist. (3) Subsection (2) does not apply if: (a) any form of an investigation or audit of pharmacy records for fraud, waste, abuse, or other intentional misrepresentation indicates that the pharmacy or pharmacist engaged in criminal wrongdoing, fraud, or other intentional misrepresentation; or (b) the reimbursement is reduced as the result of the reconciliation of a reimbursement amount under a performance contract if: (i) the performance contract lays out clear performance standards under which the reimbursement for a specific drug may be increased or decreased; and (ii) the agreement between the pharmacy benefit manager and the pharmacy or pharmacist explicitly states, in a separate document that is signed by the pharmacy benefit manager and the pharmacy or pharmacist, that the provisions of Subsection (2) do not apply. Amended by Chapter 198, 2020 General Session

Utah Code § 31A-46-305 Pharmacy reimbursement.

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 Chapter 198, 2020 General Session

Utah Code § 31A-46-306 Mailing or delivering prescription drugs.

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 enrollee who requests that the in-network retail pharmacy mail or deliver a prescription drug to the enrollee, as an ancillary service; or (c) offering or soliciting the ancillary services described in Subsection (1)(a) to an enrollee; or (2) charge an enrollee who uses an in-network retail pharmacy that offers to mail or deliver a prescription drug to an enrollee as an ancillary service a fee or copayment that is higher than the fee or copayment the enrollee would pay if the enrollee used an in-network retail pharmacy that does not offer to mail or deliver a prescription drug to an enrollee as an ancillary service. Enacted by Chapter 198, 2020 General Session

Utah Code § 31A-46-307 Pharmacy benefit manager reporting.

31A-46-307. Pharmacy benefit manager reporting. (1) A pharmacy benefit manager may not enter into or renew a contract with an insurer on or after January 1, 2021, to administer or manage rebate contracting or rebate administration unless the pharmacy benefit manager agrees to regularly report to the insurer information regarding pharmaceutical manufacturer rebates received by the pharmacy benefit manager under the contract. (2) The quality and type of information required under Subsection (1) shall be detailed, claims level information unless the pharmacy benefit manager and insurer agree to waive this requirement in a separate written agreement. Enacted by Chapter 198, 2020 General Session

Utah Code § 31A-46-308 Out-of-state mail service pharmacies -- Drugs not readily available in all pharmacies.

31A-46-308. Out-of-state mail service pharmacies -- Drugs not readily available in all pharmacies. (1) As used in this section, "out-of-state mail service pharmacy" means the same as that term is defined in Section 58-17b-102. (2) Except as provided in Subsection (3), a third party payor of pharmaceutical services within the state, or its agent or contractor, may not require a pharmacy patient to obtain prescription drug benefits from one or more out-of-state mail service pharmacies as a condition of obtaining third party payment prescription drug benefit coverage as defined in rule. (3) For a prescription drug or device that is not readily available in all pharmacies, including an injectable medication, a third party payor of pharmaceutical services may require a pharmacy patient to obtain prescription drug benefits from certain pharmacies, including one or more out-of-state mail service pharmacies. (4) (a) A violation of this section is a class A misdemeanor. (b) Each violation of this section is a separate offense. Renumbered and Amended by Chapter 198, 2020 General Session Renumbered and Amended by Chapter 372, 2020 General Session

Utah Code § 31A-46-309 Reimbursement -- Prohibitions.

31A-46-309. Reimbursement -- Prohibitions. (1) This section applies to a contract entered into or renewed on or after January 1, 2021, between a pharmacy benefit manager and a pharmacy. (2) A pharmacy benefit manager may not vary the amount it reimburses a pharmacy for a drug on the basis of whether: (a) the drug is a 340B drug; or (b) the pharmacy is a 340B entity. (3) Subsection (2) does not apply to a drug reimbursed, directly or indirectly, by the Medicaid program. (4) A pharmacy benefit manager may not: (a) on the basis that a 340B entity participates, directly or indirectly, in the 340B drug discount program: (i) assess a fee, charge-back, or other adjustment on the 340B entity; (ii) restrict access to the pharmacy benefit manager's pharmacy network; (iii) require the 340B entity to enter into a contract with a specific pharmacy to participate in the pharmacy benefit manager's pharmacy network; (iv) create a restriction or an additional charge on a patient who chooses to receive drugs from a 340B entity; or (v) create any additional requirements or restrictions on the 340B entity; or (b) require a claim for a drug to include a modifier to indicate that the drug is a 340B drug unless the claim is for payment, directly or indirectly, by the Medicaid program. Enacted by Chapter 275, 2020 General Session

Utah Code § 31A-46-310 Prohibited actions with respect to a federally qualified health center.

31A-46-310. Prohibited actions with respect to a federally qualified health center. (1) As used in this section, "federally qualified health center": (a) means the same as that term is defined in 42 U.S.C. Sec. 1395x(aa)(4); and (b) includes the pharmacy or pharmacies that are operated by or contract with a federally qualified health center described in Subsection (1)(a) to dispense drugs purchased through the federally qualified health center. (2) This section applies to a contract entered into or renewed on or after January 1, 2022, between an insurer and a pharmacy described in Subsection (1)(b). (3) An insurer may not vary the amount that the insurer reimburses to a federally qualified health center for a drug on the basis of whether: (a) the drug is a 340B drug; or (b) the pharmacy is a 340B entity. (4) Subsection (3) does not apply to a drug reimbursed, directly or indirectly, by the Medicaid program. (5) An insurer or an insurer's pharmacy service entity may not: (a) on the basis that a federally qualified health center participates, directly or through a contractual arrangement, in the 340B drug discount program: (i) assess a fee, charge-back, or other adjustment on a federally qualified health center; (ii) restrict access to the insurer's pharmacy network; (iii) require the federally qualified health center to enter into a contract with a specific pharmacy to participate in the insurer's pharmacy network; (iv) create a restriction or an additional charge on a patient who chooses to receive drugs from a federally qualified health center; or (v) create any additional requirements or restrictions on the federally qualified health center; or (b) require a claim for a drug to include a modifier to indicate that the drug is a 340B drug unless the claim is for payment, directly or indirectly, by the Medicaid program. Enacted by Chapter 317, 2021 General Session

Utah Code § 31A-46-311 Prohibited actions with respect to the 340B drug discount program.

31A-46-311. Prohibited actions with respect to the 340B drug discount program. (1) As used in this section: (a) "340B covered entity" means the same as the term "covered entity" is defined in 42 U.S.C. Sec. 256b(a)(4). (b) "340B eligible drug" means a drug purchased through the 340B drug discount program, in accordance with 42 U.S.C. Sec. 256b, by a 340B covered entity. (c) "Contracted pharmacy" means a pharmacy contracting with a 340B covered entity to dispense 340B eligible drugs. (d) "Manufacturer" means a pharmaceutical manufacturer, including an agent or affiliate of a pharmaceutical manufacturer. (e) "Pharmacy" means any place where drugs are dispensed. (2) A manufacturer may not: (a) directly or indirectly restrict or prohibit: (i) a pharmacy from contracting with a 340B covered entity, including by denying the pharmacy access to a drug that is manufactured by the manufacturer; (ii) a 340B covered entity from contracting with a pharmacy, including by denying the 340B covered entity access to a drug that is manufactured by the manufacturer; (iii) the acquisition, dispensing, or delivery of a 340B eligible drug to any location authorized by a 340B covered entity to receive the drug, unless prohibited by federal law; or (iv) a 340B covered entity from receiving a 340B eligible drug, including by imposing a time limitation on a 340B covered entity to replenish or submit a claim for a 340B eligible drug; (b) directly or indirectly: (i) require a 340B covered entity to purchase a 340B eligible drug from a supplier if the manufacturer would otherwise permit the 340B covered entity to purchase a drug that is not a 340B eligible drug from the supplier; or (ii) require a 340B covered entity or a contracted pharmacy to submit any claim data, utilization data, or information about a 340B covered entity's contracts with a third-party, unless the data or information sharing is required by federal law, as a condition for allowing: (A) the acquisition of a 340B eligible drug by a 340B covered entity; or (B) delivery of a 340B eligible drug to a 340B covered entity or a contracted pharmacy; or (c) interfere with: (i) a contract between a pharmacy and a 340B covered entity; or (ii) the ability of a pharmacy and a 340B covered entity to enter into a contract. (3) The Public Employees' Benefit and Insurance Program created in Section 49-20-103 may adjust the program's business practices to mitigate any financial impacts resulting from this section. (4) Nothing in this section is to be construed to conflict with federal law. Amended by Chapter 22, 2026 General Session

Utah Code § 31A-46-312 Options for self-funded health benefit plans.

31A-46-312. Options for self-funded health benefit plans. A pharmacy benefit manager shall offer to a self-funded health benefit plan, as an option for the self-funded health benefit plan's design, pharmacy benefit management services that: (1) comply with the provisions of Subsections 31A-22-643(4) and (5), collectively and individually; and (2) do not include spread pricing. Enacted by Chapter 525, 2025 General Session

Source: Utah Office of Legislative Research and General Counsel (le.utah.gov)URL: https://le.utah.gov/xcode/Title31A/Chapter46/31A-46-P3.html?v=C31A-46-P3_2019051420190701Fetched: 10/26/2026