Section 27-1-21

Uniformity of limits applied to fulfillment of certain drug prescriptions.

(a) For the purposes of this section, the following words shall have the following meanings:

(1) ENROLLEE. A person enrolled in a health benefit plan.

(2) HEALTH BENEFIT PLAN. Any individual or group plan, policy, or contract for health care services issued, delivered, issued for delivery, renewed in this state by a health care insurer, health maintenance organization, accident and sickness insurer, fraternal benefit society, nonprofit hospital service corporation, nonprofit medical service corporation, health care service plan, or any other person, firm, corporation, joint venture, or other similar business entity that pays for, purchases, or furnishes health care services to patients, insureds, or beneficiaries in this state. The term includes, but is not limited to, entities created pursuant to Article 6 of Chapter 4 of Title 10. The term shall not include any collective bargaining agreement or any employee welfare benefit plan as defined in 29 U.S.C. Section 1002 (1) or any third party administrator to the extent it provides services to an employee welfare benefit plan. For the purposes of this section, a health benefit plan located or domiciled outside of the State of Alabama is deemed to be subject to the provisions of this section if it receives, processes, adjudicates, pays, or denies claims for health care services submitted by or on behalf of patients, insureds, or beneficiaries who reside in the State of Alabama or who receive health care services in the State of Alabama.

(b) Each health benefit plan shall apply the same coinsurance, copayment, deductible, and quantity limit factors within the same employee group and other plan-sponsored group factors to all drug prescriptions filled by a pharmacy provider, whether by a retail provider or a mail service provider, provided the retail provider complies with the same terms, conditions, services, and price as a mail service provider. Nothing in this section shall be construed to prohibit the health benefit plan from applying different coinsurance, copayment, and deductible factors within the same employer group and other plan-sponsored group between generic and brand name drugs, nor prohibit an employer or other plan-sponsored group from offering multiple options or choices of health benefit plans, including, but not limited to, cafeteria benefit plans.

(c) A health benefit plan shall not set a limit on the quantity of drugs which an enrollee may obtain at any one time with a prescription, unless the limit is applied uniformly to all pharmacy providers who comply with the same terms, conditions, services, and price as mail service providers.

(Act 2000-327, p. 523, §1.)