PURPOSE: This rule carries out the provisions of section 354.535, RSMo H.B. 335 (89th General Assembly, First Regular Session, 1997).

1. (1) Except as otherwise indicated in this rule, the terms used in this rule shall have the same meaning as those terms defined in section 354.400 and as used in section 354.535.
2. (2) A health maintenance organization

3. (HMO) offering enrollees a particular package of coinsurance, copayment, and deductible factors must offer to allow any pharmacy to sell prescriptions with that package of factors, if and only if the pharmacy—

   1. (A) Is in the HMO’s network; and
   2. (B) Is willing to meet the explicit product cost determination set by the HMO; and
   3. (C) Has been granted a permit or license from the Missouri Board of Pharmacy to operate in this state.
4. (3) If a pharmacy provider rejects a contract offered by the HMO containing the HMO’s explicit product cost determination and the participation of that provider in the network is necessary for the HMO to comply with network adequacy provisions of section 354.400 to 354.636 or a rule adopted to implement those sections, the HMO may offer such other contracts as may be necessary to secure the pharmacy provider’s participation in the network, but no such other contract need be offered to other pharmacy providers.
5. (4) No HMO may establish a limit on the quantity of drugs which an enrollee may obtain at any one time with a prescription, unless such limit is uniformly applied to all pharmacy providers in the HMO’s network. A “limit on the quantity of drugs” means any limitation of the length of a prescription or quantity of drugs. If an enrollee may have filled a prescription of a given length or quantity by any pharmacy provider in the HMO’s network, the HMO must ensure that the enrollee may have such prescription filled by all pharmacy providers in the HMO’s network.
6. (5) An explicit product cost determination means and must be stated as a percentage of average wholesale price (AWP), maximum allowable cost (MAC) or similar measure plus a dispensing fee. AUTHORITY: section 354.485, RSMo 1994.* Original rule filed Nov. 3, 1997, effective June 30, 1998. *Original authority: 354.485, RSMo 1983.