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Department of Insurance
The Pennsylvania Insurance Department Pharmacist Portal
Submitter Information
Submitter's First Name
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Submitter's Last Name
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Submitter's Phone Number
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Submitter's E-mail Address
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Insured Information
Insured's First Name
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Insured's Last Name
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Type of Policy
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HMO
PPO
EPO
POS
Medicare
Medicaid
CHIP
Commercial Insurance
Other
Insurance Company Name
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Insurance Card ID Number
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In what state was policy sold?
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Outside of United States
Group #
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PCN BIN #
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Claim #
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Rx #
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Inquiry Type (select all that apply)
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Specialty Drug Referral
Clawbacks
Steering
Network Adequacy
Reimbursements
Rebates
Contract Info
Specialty Drug Referral
PBM Name
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PBM E-mail Address
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Name of drug you believe shouldn't be labeled a Specialty Drug
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RxCUIÂ or NDC
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RxBIN
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RxPCN
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1. The drug does not have a cost that meets or exceeds the cost of a drug on the specialty tier of Medicare Part D under 42 CFR 423.104(d)(2)(iv) (relating to requirements related to qualified prescription drug coverage).
No
Yes
The drug requires specialized product handling or administration by the dispensing pharmacy.
The drug requires specialized clinical care, including, but not limited to, frequent dosing adjustments, clinical monitoring/expanded patient service, intensive patient counseling/ongoing clinical support (such as individualized disease or therapy management) to support patient outcomes.
The drug is prescribed for a covered individual with a rare, complex/chronic, or life-threatening medical condition.
The drug has limited or exclusive distribution and is not typically stocked or dispensed by a retail pharmacy.
The drug does not meet any of these criteria.
3. The drug is not listed as a specialty drug on the medical assistance fee-for-service specialty pharmacy drug list.
No
Yes
Please share any extra details that could help us review this inquiry.
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Clawbacks
Charged a patient more for a covered prescription drug than the net reimbursement amount that was paid to the pharmacy by a health plan, insurer, or PBM.
Charged a patient more for a covered prescription drug than what they would pay if buying it without insurance.
Was required to remit to a health plan, insurer, or PBM any difference between the cost-sharing the patient paid to the pharmacy and the cost-sharing owed under the patient's health benefit plan for a covered prescription drug.
Please provide details about the situations or transactions marked above, including the name of the covered drug. Also, include any additional information that can help us review this inquiry.
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Steering
The insured must exclusively use a mail-order pharmacy.
Mail-Order Pharmacy Name
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The insured must exclusively use a PBM Retail pharmacy affiliate. (An affiliate is someone who controls, is controlled by, or shares control with the specified person.)
PBM Retail Pharmacy Affiliate Name
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The insured is not allowed to use your pharmacy.
Are you an in-network pharmacy/pharmacist?
No
Yes
Do you meet and agree to the PBM contract’s terms and conditions - including reimbursements?
No
Yes
The insured did not ask for their prescriptions to be transferred to another pharmacy, but they were transferred anyway.
The insurer or PBM offered financial incentives (like cost-sharing adjustments) for the exclusive benefit of a PBM Retail Pharmacy affiliate.
The insured was auto-enrolled in mail-order pharmacy services for a non-specialty prescription drug.
The insured was auto-enrolled in mail-order pharmacy services within the first 90 days of a new maintenance medication, and was not given an option to opt out.
Pharmacy called patient’s physician without the patient’s consent.
Please share any extra details that could help us review this inquiry.
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Network Adequacy
A PBM's network is limited to affiliated pharmacies only.
A PBM does not have an adequate retail pharmacy network, including pharmacies not affiliated with the PBM, that provide access within a reasonable distance from the patient's home.
Identify the out-of-network retail pharmacies that are within the "reasonable distance" standards
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I hear complaints from patients about their travel time to a pharmacy that is not affiliated with any PBM.
I am aware of patients who are experiencing issues traveling to an in-network pharmacy that is contracted with a PBM.
I have other information that demonstrates patients do not have convenient access to pharmacies other than PBM-affiliated pharmacies.
Please share any extra details that could help us review this inquiry.
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Reimbursements
I am being reimbursed less than the amount the PBM reimburses a PBM-affiliated retail pharmacy in Pennsylvania for providing the same pharmacist services.
A FQHC or another 340(B) entity is being reimbursed less than a similar entity not participating in the FQHC or 340(B) program.
I am being required by the Insurer/PBM to provide a brand name drug or biological product when a less expensive generically equivalent drug or interchangeable biological product is available and the patient and prescriber allowed for substitution; and, if the prescription is for a PACE/PACENET patient, the substitution is permitted by the program.
The prescription is for a PACE/PACENET patient, and I am being reimbursed less than the NADAC price and/or Wholesale Acquisition Cost (WAC) for the drug.
Please provide details about the situations or transactions marked above. Also, include any additional information that can help us review this inquiry.
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Rebates
A health insurer has not received, via pass through, a prescription drug manufacturer rebate from a PBM.
No
Yes
Please provide details about the situation noted above, including any additional information that can help us review this inquiry.
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Please explain your role in the rebate process, if any.
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Contract Info
A participation contract, between a PSAO or pharmacy and a PBM, has been altered, beyond the original terms, and was not agreed to by both parties prior to the alterations.
Identify the parties to the contract and the contract alterations.
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A PBM is designating a prescription drug as a specialty drug, or requiring that a prescription drug be dispensed exclusively at a specialty pharmacy, but the drug should not be considered a specialty drug.
A PBM is not providing information about the schedule and total for any fee, such as a transaction fee, charged by the PBM for participation in the PBM's network.
Please share any extra details that could help us review this inquiry.
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