CurrentWest Virginia Offices of the Insurance CommissionerPolicy N/A

Specialty Drug Networks

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Applies in West Virginia to PBMs, health benefit plans, insurers, and applicable health care organizations. Requires adequate pharmacy networks with both physical and mail-order access and preserves covered individuals’ choice among participating pharmacies.

Policy Summary

PayerWest Virginia Offices of the Insurance Commissioner

PolicySpecialty Drug Networks

Policy CodePolicy N/A

Change TypeClarified requirements

Effective DateN/A

Next Review DateN/A

Key ActionMaintain an adequate pharmacy network with both mail-order benefits and physical pharmacy stores, including for specialty drugs.

SourceLink

POLICY UPDATE CHANGES

The Insurance Commissioner clarified that a specialty-drug subnetwork consisting solely of mail-order pharmacies violates West Virginia network adequacy and pharmacy freedom-of-choice requirements.

The bulletin clarified that pharmacy freedom-of-choice requirements apply broadly to PBMs and health benefit plans providing pharmaceutical benefits to West Virginia residents.

2Required pharmacy network channels

7Pharmacy choice protections

0Mail-order-only specialty exceptions

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CurrentWest Virginia Offices of the Insurance CommissionerPolicy N/A

Specialty Drug Networks

Customize your policy alerts

Sign up for all West Virginia Offices of the Insurance Commissioner policy alerts

Know when West Virginia Offices of the Insurance Commissioner releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerWest Virginia Offices of the Insurance Commissioner

PolicySpecialty Drug Networks

Policy CodePolicy N/A

Change TypeClarified requirements

Effective DateN/A

Next Review DateN/A

Key ActionMaintain an adequate pharmacy network with both mail-order benefits and physical pharmacy stores, including for specialty drugs.

SourceLink

POLICY UPDATE CHANGES

The Insurance Commissioner clarified that a specialty-drug subnetwork consisting solely of mail-order pharmacies violates West Virginia network adequacy and pharmacy freedom-of-choice requirements.

The bulletin clarified that pharmacy freedom-of-choice requirements apply broadly to PBMs and health benefit plans providing pharmaceutical benefits to West Virginia residents.

2Required pharmacy network channels

7Pharmacy choice protections

0Mail-order-only specialty exceptions

AllCovered West Virginia plans and PBMs

Pharmacy Network and Choice Requirements

Specialty Drug Network Adequacy

A compliant specialty drug network must provide adequate and accessible pharmacy services through both physical and mail-order channels; specialty drugs may not be restricted to a mail-order-only subnetwork.

ALL of the following

Network adequacy and access
- Maintain an adequate and accessible network for prescription drugs that provides convenient patient access to pharmacies within a reasonable distance from the patient's residence.
- Maintain a mix of mail-order benefits and physical pharmacy stores in West Virginia; the network may not consist only of mail-order benefits.
- Treat specialty pharmacies as part of the pharmacy network when they provide prescription services to covered individuals, including pharmacies that dispense particular types of prescriptions or serve particular patient populations or health care settings.
Specialty drug access
- Do not create or maintain a specialty-drug subnetwork consisting solely of mail-order pharmacies when physical in-network pharmacies can dispense the specialty drug.
- Ensure that any specialty pharmacy, whether a mail-order pharmacy or a physical retail pharmacy, has the skill, capability, personnel, storage, shipping, patient-education, and clinical-support capacity required for the specialty drugs it dispenses.
- Provide covered individuals access to specialty drugs through qualifying physical retail pharmacies and mail-order pharmacies; no specialty-drug carve-out permits eliminating that choice.

Freedom of Pharmacy Choice

Covered individuals must be free to choose a participating pharmacy or pharmacist on nondiscriminatory benefit terms. These protections apply to PBMs and health benefit plans providing pharmaceutical services benefits to West Virginia residents, including applicable ERISA and workers' compensation arrangements.

ALL of the following

Do not prohibit or limit a covered individual from selecting a pharmacy or pharmacist of the individual's choice when that pharmacy or pharmacist has agreed to participate in the plan according to the insurer's offered terms.
Allow a pharmacy or pharmacist to participate as a contract provider when it agrees to provide pharmacy services, including prescription drugs, that meet the plan's terms and requirements and agrees to the insurer's reimbursement terms.
Impose copayments, fees, and other conditions equally on beneficiaries in the same benefit category, class, or copayment level when they receive services from a contract provider.
Do not impose a monetary advantage or penalty that affects the beneficiary's choice among participating pharmacies or pharmacists, including a higher copayment, reduced reimbursement, or preferential promotion of one participating pharmacy over another.

Operational Requirements

Documentation Required

Maintain mixed specialty pharmacy access

Maintain an adequate and accessible pharmacy network in West Virginia that includes both mail-order benefits and physical pharmacy stores, including for specialty drugs.

Denial Risk

Do not restrict specialty drugs to mail order

Do not create or operate a specialty-drug subnetwork limited solely to mail-order pharmacies when a qualified physical pharmacy can dispense the specialty drug. Such a restricted subnetwork violates network adequacy and pharmacy freedom-of-choice requirements.

Key Terms

Network

DefinitionA pharmacy or group of pharmacies that agrees to provide prescription services to covered individuals on behalf of a covered entity or group of covered entities in exchange for payment by a pharmacy benefits manager or pharmacy services administration organization.

Included pharmacy typesThe term includes pharmacies that dispense outpatient prescriptions or particular types of prescriptions, serve particular types of covered individuals, or provide services in particular health care settings.

Specialized networksNetwork examples include specialty, institutional, and long-term care facility networks.

Specialty drugs

DefinitionDrugs used to treat complex, chronic conditions such as cancer, multiple sclerosis, organ transplants, or other rare diseases or conditions.

Special handling

Policy Summary

PayerWest Virginia Offices of the Insurance Commissioner

PolicySpecialty Drug Networks

Policy CodePolicy N/A

Change TypeClarified requirements

Effective DateN/A

Next Review DateN/A

Key ActionMaintain an adequate pharmacy network with both mail-order benefits and physical pharmacy stores, including for specialty drugs.

SourceLink

On This Page

Do not reduce allowable reimbursement for pharmacy services because the beneficiary selects a pharmacy of choice that has enrolled under the terms offered to all pharmacies in the plan's coverage area.

Do not require a beneficiary, as a condition of payment or reimbursement, to purchase pharmacy services or prescription drugs exclusively through a mail-order pharmacy.

Do not impose a copayment, reimbursement amount, reimbursable supply limit, or other payment or purchasing condition that is more costly or restrictive than the condition applicable through a mail-order pharmacy or another pharmacy willing to provide the same services or products for the same cost and copayment.

When a specialty pharmacy meets the applicable terms and requirements, allow the covered individual to select it and allow the pharmacy to participate in the network regardless of whether it is a mail-order pharmacy or a physical store.

Honor covered-pharmacy choice

Allow covered individuals to select any pharmacy or pharmacist that has agreed to participate under the plan’s applicable terms. A qualifying specialty pharmacy must be allowed to participate whether it is a mail-order pharmacy or a physical store.

Billing Rule

Apply equivalent pharmacy payment terms

Do not impose more costly or restrictive conditions based on the covered individual’s selection of a participating pharmacy when the same service or product is available on equivalent terms.

Do not impose a higher copayment or fee.
Do not reduce reimbursement or promote one participating pharmacy over another through payment methods.
Do not restrict the reimbursable number of supply days.
Do not impose any other more restrictive payment or purchase condition based on pharmacy choice.

Denial Risk

Do not mandate mail-order fulfillment

Do not require a covered individual, as a condition of payment or reimbursement, to obtain prescription drugs exclusively through a mail-order pharmacy. West Virginia provisions do not provide a specialty-drug exception to this requirement.

Documentation Required

Verify specialty pharmacy capability

Ensure that every specialty pharmacy, whether mail-order or a physical retail store, has the skill, capability, and personnel to provide required patient education and clinical support, along with the necessary storage and shipping capacity for the specialty drugs it dispenses.

Specialty drugs may require special handling, provider coordination, and patient education for safe and effective use.

Pharmacy supportSpecialty pharmacies must have the skill, capability, and personnel to provide required patient education and clinical support.

Storage and shippingSpecialty drugs may require unique storage and shipping arrangements.