40 Pa.C.S. Ch. 40

in effect

40 Pa.C.S. § 4001 Definitions.

The following words and phrases when used in this chapter shall have the meanings given to them in this section unless the context clearly indicates otherwise: "Health insurance policy." An individual or group policy, subscriber contract, certificate or plan issued by an insurer that provides medical or health care coverage. The term does not include any of the following: (1) An accident only policy. (2) A credit only policy. (3) A long-term care or disability income policy. (4) A specified disease policy. (5) A Medicare supplement policy. (6) A TRICARE policy, including a Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) supplement policy. (7) A fixed indemnity policy. (8) A dental only policy. (9) A vision only policy. (10) A workers' compensation policy. (11) An automobile medical payment policy. (12) Another similar policy providing for limited benefits. "Insurer." An entity licensed by the department with accident and health authority to issue a health insurance policy that is offered or governed under any of the following: (1) The act of May 17, 1921 (P.L.682, No.284), known as The Insurance Company Law of 1921, including section 630 and Article XXIV of that act. (2) The act of December 29, 1972 (P.L.1701, No.364), known as the Health Maintenance Organization Act. (3)

40 Pa.C.S. § 4002 Prorated daily cost-sharing rate.

A health insurance policy shall permit and apply a prorated daily cost-sharing rate to maintenance medications that are dispensed by a pharmacy as a partial supply if the pharmacist or prescriber determines the fill or refill to be in the best interest of the patient and the patient requests or agrees to a partial supply for the purpose of medication synchronization. The fill or refill under this section shall be limited to three times per year for each maintenance medication for a covered individual. For each clinically necessary synchronization thereafter, approval may be required at the discretion of the health insurance policy.

40 Pa.C.S. § 4003 Denial of coverage.

(a) Partial supply.--A health insurance policy providing prescription drug coverage may not deny coverage for the dispensing of a maintenance medication that is dispensed by a network pharmacy on the basis that the dispensing is for a partial supply if the prescriber or pharmacist determines the fill or refill to be in the best interest of the patient and the patient requests or agrees to a partial supply for the purpose of medication synchronization. (b) Denial codes.--The health insurance policy shall accept early refill and partial supply requests for maintenance medications dispensed for the purpose of medication synchronization using the submission clarification and message codes as adopted by the National Council for Prescription Drug Programs or alternative codes provided by the health insurance policy. (c) Compliance.--Nothing in this chapter may prohibit a health insurance policy from using other methods to comply with this chapter.

40 Pa.C.S. § 4004 Certain payment structures prohibited.

(a) Prorated dispensing fees.--A health insurance plan providing prescription drug coverage may not use payment structures incorporating prorated dispensing fees. (b) Full payment.--Dispensing fees for a partial supply or refilled prescriptions shall be paid in full for each maintenance medication dispensed, regardless of any prorated copay for the beneficiary or fee paid for alignment services.

40 Pa.C.S. § 4005 Application of chapter.

(a) Prescription drugs.--This chapter does not apply to prescription drugs that are: (1) unit-of-use packaging for which medication synchronization is not possible; or (2) controlled substances classified in Schedule II under section 4(2) of the act of April 14, 1972 (P.L.233, No.64), known as The Controlled Substance, Drug, Device and Cosmetic Act. (b) Health insurance policies.--This chapter shall apply to health insurance policies as follows: (1) For a health insurance policy for which either rates or forms are required to be filed with the Federal Government or the Insurance Department, this chapter shall apply to a health insurance policy for which a form or rate is first permitted to be used on or after the effective date of this section. (2) For a health insurance policy for which neither rates nor forms are required to be filed with the Federal Government or the Insurance Department, this chapter shall apply to a health insurance policy issued or renewed on or after the effective date of this section.

Source: Open US Law by Vaquill AI (CC BY 4.0)URL: https://www.palegis.us/statutes/consolidated/view-statute?txtType=HTM&ttl=40Fetched: 10/16/2026