reglab/statecodes huggingface dataset:
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1720. Definitions.

As used in this article:
(1) "Closed panel health plan" means a network plan that requires an insured or a member to seek covered health care services or supplies, except in the case of emergency, exclusively from network providers.
(2) "Eligibility" means the time at which an insured or a member is entitled to enroll under the terms of the coverage offered by the network plan by virtue of:
(a) terms of employment;
(b) an annual open enrollment period; or
(c) at any other time during which the network plan's procedures or South Carolina law allows enrollment in the plan or allows renewal in the plan.
(3) "Health insurance coverage" means coverage as defined in Section 38-71-840(14).
(4) "Network plan" means a plan as defined in Section 38-71-840(24).
(5) "Network providers" means those entities and individuals who provide covered health care services or supplies to an insured or a member pursuant to a contract with a network plan to act as a participating provider.
(6) "Open panel health plan" means a plan which permits an insured or a member to seek covered health care services or supplies exclusively from an out-of-network provider.
(7) "Out-of-network providers" means those entities and individuals who provide covered health care services or supplies who are not network providers.
(8) "Point-of-service option" means a network plan that provides benefits for services or supplies provided by network providers and provides benefits for services or supplies provided by nonparticipating network providers.
(a) In-network covered health care services provided through a licensed health maintenance organization are governed by and subject to the provisions of Chapter 33 of this title.
(b) Out-of-network coverage may be underwritten by and provided through the health maintenance organization or through a licensed insurance company. The Director of Insurance may promulgate regulations as necessary or appropriate to implement the provisions of this subsection.
(c) Any benefit limitation for out-of-network covered health care services applied to an annual or lifetime benefit limitation may be offset against the benefit limitation applicable to in-network covered health care services or supplies, regardless of whether out-of-network coverage is provided through a health maintenance organization or an insurance company.
(d) The rating methods used to establish premiums for the point-of-service option must be based on actuarially sound principles.
HISTORY: 1998 Act No. 441, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1740. Responsibility for errors and omissions by parties to managed care participating provider agreements; limitations on network providers to discuss treatments, risks and legal obligations with an insured or member prohibited; permissible limitations.

(A) For purposes of any health insurance plan, health maintenance organization, or any other health benefits plan offered in this State under the jurisdiction of South Carolina law:
(1) Each party to a managed care participating provider agreement is responsible for the legal consequences and costs of his own acts or omissions, or both, and is not responsible for the acts or omissions, or both, of the other party. A clause in a participating provider agreement to the contrary is unlawful in this State, as a matter of public policy, whether entered into before or after January 1, 1999.
(2) To the extent that a network plan requires an insured or a member to receive health benefits through a network of providers, the provisions of participating provider agreements may not limit the network provider's:
(a) ability to discuss with an insured or a member, the treatment options available to the insured or member, risks associated with treatments, utilization management decisions, and recommended course of treatment;
(b) legal obligations to an insured or a member as specified under the provider's professional license.
(B) Nothing in this section:
(1) prevents a network plan from prohibiting disclosure by network providers of trade secrets;
(2) subjects a network plan to liability for clinical decisions made solely by the network provider; and
(3) limits the ability of the network plan otherwise prudently to administer its provider contracts.
HISTORY: 1998 Act No. 441, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1750. Disclosures required of network plans.

A network plan must disclose in writing, using the plain and ordinary meaning of words so as reasonably to ensure comprehension by the insured or member, and make available to an insured or a member at the time of enrollment:
(1) services or benefits under the plan, including limitations on services;
(2) rules regarding copayments, prior authorization, and review requirements that apply to the benefits plan of the insured or member;
(3) potential financial liability for the insured or member to pay for a portion of services received from an out-of-network provider;
(4) financial obligations of the insured or member for items and services both in and out of the network;
(5) the number, mix, and distribution of network providers and a current list of network providers upon request from an insured or a member;
(6) the rights and responsibilities of an insured or a member, including an explanation of any appeals process for the denial of care or services under the plan;
(7) the existence of any limitations on the choice of providers by an insured or a member.
HISTORY: 1998 Act No. 441, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1820. Appeals process; dismissal; copy of audit findings.

Section effective until January 1, 2024. See, also, Section 38-71-1820 effective January 1, 2024.
(A) Each entity that conducts an audit of a pharmacy shall establish an appeals process under which a pharmacy may appeal an unfavorable preliminary audit report to the entity.
(B) If, following the appeal, the entity finds that an unfavorable audit report or any portion of the unfavorable audit report is unsubstantiated, the entity shall dismiss the unsubstantiated portion of the audit report without any further proceedings.
(C) Each entity conducting an audit shall provide a copy, if required under the terms of the contract with the responsible party, of the audit findings to the plan sponsor after completion of any appeals process.
HISTORY: 2012 Act No. 250, Section 1, eff January 1, 2013.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1830. Recoupment.

Section effective until January 1, 2024. See, also, Section 38-71-1830 effective January 1, 2024.
(A) Recoupments of any funds disputed on the basis of an audit must occur only after final internal disposition of the audit, including the appeals process as provided for in Section 38-71-1820, unless fraud or misrepresentation is reasonably suspected.
(B) Recoupment on an audit must be refunded to the responsible party as contractually agreed upon by the parties involved in the audit.
(C) The entity conducting the audit may charge or assess the responsible party, directly or indirectly, based on amounts recouped if both of the following conditions are met:
(1) the responsible party or payor and the entity conducting the audit have entered into a contract that explicitly states the percentage charge or assessment to the responsible party; and
(2) a commission or other payment to an agent or employee of the entity conducting the audit is not based, directly or indirectly, on amounts recouped.
HISTORY: 2012 Act No. 250, Section 1, eff January 1, 2013.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1840. Exemptions.

Section effective until January 1, 2024. See, also, Section 38-71-1840 effective January 1, 2024.
The provisions of this article do not apply to an audit, review, or investigation:
(1) that involves alleged insurance fraud or abuse, Medicare fraud or abuse, or other fraud or misrepresentation; or
(2) conducted by or on the behalf of the Department of Health and Human Services in the performance of its duties in administering Medicaid under Titles XIX and XXI of the Social Security Act.
HISTORY: 2012 Act No. 250, Section 1, eff January 1, 2013.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1820. Appeals process; dismissal; copy of audit findings.

Section effective January 1, 2024. See, also, Section 38-71-1820 effective until January 1, 2024.
(A) Each entity that conducts an audit of a pharmacy shall establish an appeals process under which a pharmacy may appeal an unfavorable preliminary audit report to the entity.
(B) If, following the appeal, the entity finds that an unfavorable audit report or any portion of the unfavorable audit report is unsubstantiated, the entity shall dismiss the unsubstantiated portion of the audit report without any further proceedings.
(C) Each entity conducting an audit shall provide a copy, if required under the terms of the contract with the responsible party, of the audit findings to the plan sponsor after completion of any appeals process.
HISTORY: 2012 Act No. 250, Section 1, eff January 1, 2013; 2023 Act No. 30 (S.520), Section 1, eff January 1, 2024.
Editor's Note
2023 Act No. 30, Section 7, provides as follows:
"SECTION 7. This act takes effect January 1, 2024, but the recurring examinations by the Department of Insurance provided for in Sections 38-71-2250(B)(1) and 38-71-2340(B)(1) must not begin before January 1, 2025."
Effect of Amendment
2023 Act No. 30, Section 1, reenacted the section with no apparent change.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1830. Recoupment.

Section effective January 1, 2024. See, also, Section 38-71-1830 effective until January 1, 2024.
(A) Recoupments of any funds disputed on the basis of an audit must occur only after final internal disposition of the audit, including the appeals process as provided for in Section 38-71-1820 or the external review pursuant to Section 38-71-2240, unless fraud or misrepresentation is reasonably suspected.
(B) Recoupment on an audit must be refunded to the responsible party as contractually agreed upon by the parties involved in the audit.
(C) The entity conducting the audit may charge or assess the responsible party, directly or indirectly, based on amounts recouped if both of the following conditions are met:
(1) the responsible party or payor and the entity conducting the audit have entered into a contract that explicitly states the percentage charge or assessment to the responsible party; and
(2) a commission or other payment to an agent or employee of the entity conducting the audit is not based, directly or indirectly, on amounts recouped.
HISTORY: 2012 Act No. 250, Section 1, eff January 1, 2013; 2023 Act No. 30 (S.520), Section 1, eff January 1, 2024.
Editor's Note
2023 Act No. 30, Section 7, provides as follows:
"SECTION 7. This act takes effect January 1, 2024, but the recurring examinations by the Department of Insurance provided for in Sections 38-71-2250(B)(1) and 38-71-2340(B)(1) must not begin before January 1, 2025."
Effect of Amendment
2023 Act No. 30, Section 1, in (A), inserted "or the external review pursuant to Section 38-71-2240".
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1840. Exemptions.

Section effective January 1, 2024. See, also, Section 38-71-1840 effective until January 1, 2024.
The provisions of this article do not apply to an audit, review, or investigation:
(1) that involves alleged insurance fraud or abuse, Medicare fraud or abuse, or other fraud or misrepresentation;
(2) conducted by or on the behalf of the Department of Health and Human Services in the performance of its duties in administering Medicaid under Titles XIX and XXI of the Social Security Act; or
(3) notwithstanding the exemptions under subsections (1) and (2) of this section, contracts between the South Carolina Department of Health and Human Services and Medicaid-managed care organizations must include provisions for biannual audits of Medicaid-managed care organizations' pharmacy pricing and include limitations on any pharmacy benefits manager contract arrangements that bill the Medicaid program for more than the total price paid to pharmacies for actual claims.
HISTORY: 2012 Act No. 250, Section 1, eff January 1, 2013; 2023 Act No. 30 (S.520), Section 1, eff January 1, 2024.
Editor's Note
2023 Act No. 30, Section 7, provides as follows:
"SECTION 7. This act takes effect January 1, 2024, but the recurring examinations by the Department of Insurance provided for in Sections 38-71-2250(B)(1) and 38-71-2340(B)(1) must not begin before January 1, 2025."
Effect of Amendment
2023 Act No. 30, Section 1, added (3) and made nonsubstantive changes.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1930. Application of this article.

(A) Except as provided in subsection (B), this article applies to all health carriers that provide or perform utilization review, including those plans subject to regulation under Chapter 33.
(B) This article does not apply to the administrative services performed on behalf of a self-funded plan subject to the Employee Retirement Income Security Act (ERISA) of 1974.
(C) For purposes of this article, notice to the subscriber or insured entitled to covered benefits under a health benefit plan shall constitute notice to the covered person. This subsection does not affect the health plan's obligations under a court order requiring a parent to provide health coverage pursuant to Section 63-17-2100, et seq.
HISTORY: 2000 Act No. 380, Section 3A.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1940. Notice of right to request a review; notice of adverse determination.

(A) A health carrier shall notify the covered person in writing of the right to request an external review and include the appropriate statements and information set forth in subsection (B) at the time the health carrier sends written notice of either an adverse determination or a final adverse determination.
(B)(1) The health carrier shall include in the notice required under subsection (A) a clear and concise description of the right of the covered person to request a standard external review pursuant to Section 38-71-1970 or an expedited external review pursuant to Section 38-71-1980 upon receipt of an adverse determination or a final adverse determination and the circumstances under which the covered person is not required to exhaust the health carrier's internal appeal process or is considered to have exhausted the health carrier's internal appeal process pursuant to Section 38-71-1960.
(2) In addition to the information to be provided pursuant to item (1), the health carrier shall include a brief description of both the standard and expedited external review procedures.
(3) As part of any forms provided under item (2), the health carrier shall include an authorization form, or other document promulgated or approved by the director or his designee, by which the covered person, for purposes of conducting an external review under this article, authorizes the health carrier to disclose protected health information, including medical records, concerning the covered person that are pertinent to the external review.
(C) A notice, statement, or form required by this section must achieve a score of no lower than 70 on the Flesch Reading East Test and must be printed in no smaller than 12 point type. No part of the notice, statement, or form may be printed in all capitals. A notice, statement, or form required by this section must include a statement of the right of the covered person to contact the director or his designee for assistance. The statement must include the telephone number and address of the director or his designee.
(D) A notice, statement, or form required by this section must be approved by the Department of Insurance. The director or his designee shall promulgate standard language, in a specified font size and type for any notice, statement, or form required by this section. Use of the standard language in the specified font size and type promulgated by the department pursuant to this section shall constitute compliance with the notice requirements of this section.
HISTORY: 2000 Act No. 380, Section 3A.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1950. Requests for external review.

(A) All requests for external review must be made in writing to the health carrier.
(B) A covered person or his authorized representative may make a request for an external review of an adverse determination or final adverse determination only when the amount payable for covered benefits is at least five hundred dollars.
(C) A covered person is not entitled to an external review of a retrospective review determination unless the covered person has exhausted the health carrier's internal appeal process and may be held financially responsible for the covered benefits.
HISTORY: 2000 Act No. 380, Section 3A.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1960. Exhaustion of internal appeal process.

(A)(1) Except in cases where the covered person's treating physician has certified in writing that the covered person has a serious medical condition, or where the denial of coverage is based on a determination that the health care service or treatment recommended or requested is experimental or investigational and the covered person's treating physician has provided the certifications required pursuant to Section 38-71-1980, a request for a standard or expedited external review may not be made until the covered person has exhausted the health carrier's internal appeal process.
(2) A covered person is considered to have exhausted the health carrier's internal appeal process for purposes of this section, if the covered person or his authorized representative:
(a) has filed an appeal involving an adverse determination pursuant to the health carrier's internal appeal process; and
(b) the health carrier has not issued a written decision within the time frames set forth in the health carrier's internal appeals process after receipt of all information necessary to complete the appeal and the covered person or his authorized representative has not agreed to a delay.
(B) A request for an external review of an adverse determination may be made before the covered person has exhausted the health carrier's internal appeal process whenever the health carrier agrees to waive the exhaustion requirement.
(C) If the requirement to exhaust the health carrier's internal appeal process is waived under subsection (B), the covered person or his authorized representative may file a request in writing for an external review.
HISTORY: 2000 Act No. 380, Section 3A.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1990. External review decisions final; exceptions.

(A) An external review decision is binding on the health carrier.
(B) An external review decision is binding on the covered person except to the extent the covered person has other remedies available under applicable federal or state law. If such other remedies are available, the covered person or his authorized representative may not, in these proceedings, utilize, disclose, or introduce in evidence information generated during or findings reached by the independent review organization.
(C) A covered person or his authorized representative may not file a subsequent request for external review involving the same adverse determination or final adverse determination.
HISTORY: 2000 Act No. 380, Section 3A.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-2000. Approval of independent review organizations.

(A) The director or his designee shall approve independent review organizations eligible to be assigned to conduct external reviews to ensure that an independent review organization satisfies the minimum qualifications established under Section 38-71-2010.
(B) The director or his designee shall develop an application form for initially approving and for reapproving independent review organizations to conduct external reviews and may establish an advisory committee with appropriate representation to review the applications. No member of the advisory committee may be liable to any person for any acts or omissions arising out of or related to the approval or reapproval of independent review organizations pursuant to this act.
(C)(1) An independent review organization wishing to be approved to conduct external reviews under this article shall submit the application form and include with the form all documentation and information necessary for the director or his designee to determine if the independent review organization satisfies the minimum qualifications established under Section 38-71-2010.
(2) The director or his designee may charge an application fee that independent review organizations shall submit to the director or his designee with an application for approval and reapproval.
(D)(1) Except as provided in item (2), an approval is effective for two years.
(2) The independent review organization must notify the director or his designee of any material changes in qualifications, including removal or loss of accreditation by a nationally recognized private accrediting entity, approved by the director or his designee pursuant to subsection (E). Whenever the director or his designee determines that an independent review organization no longer satisfies the minimum requirements established under Section 38-71-2010 or has violated a provision of this article, the director or his designee shall terminate the approval of the independent review organization and remove the independent review organization from the list of independent review organizations approved to conduct external reviews under this article that is maintained by the director or his designee pursuant to subsection (F).
(E) An independent review organization accredited by a nationally recognized private accrediting entity with established and maintained standards for independent review organizations that meet the minimum qualifications established pursuant to Section 38-71-2010, which accrediting entity has been approved by the director or his designee, may be deemed to meet the minimum qualification requirements set forth in Section 38-71-2010.
(F) The director or his designee shall maintain and periodically update a list of approved independent review organizations and approved nationally recognized private accrediting entities.
(G) The director or his designee may promulgate regulations or bulletins to carry out the provisions of this section.
HISTORY: 2000 Act No. 380, Section 3A.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-2020. Liability of independent review organizations and personnel.

No independent review organization, or employee, officer, or director of an independent review organization or health care professional who furnishes services to an independent review organization is liable to any person for any acts or omissions arising out of or related to an external review conducted pursuant to this article, except for cases of wilful and intentional misconduct.
HISTORY: 2000 Act No. 380, Section 3A.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-2030. External review; written records; reports.

(A)(1) An independent review organization assigned pursuant to Section 38-71-1970 or Section 38-71-1980 to conduct an external review shall maintain written records in the aggregate and by health carrier on all requests for external review for which it conducted an external review during a calendar year and submit a report to the director or his designee, as required under item (2).
(2) Each independent review organization required to maintain written records on all requests for external review pursuant to item (1) for which it was assigned to conduct an external review shall submit to the director or his designee, no later than March first of each year and upon request by the director or his designee, a report in the format specified by the director or his designee.
(3) The report shall include in the aggregate and for each health carrier:
(a) the total number of requests for external review and the manner in which they were resolved;
(b) the average length of time for resolution;
(c) a summary of the types of coverages or cases for which an external review was sought, as provided in the format required by the director or his designee; and
(d) any other information the director or his designee may request or require.
(4) The independent review organization shall retain the written records required pursuant to this subsection for at least three years.
(B)(1) Each health carrier shall maintain written records in the aggregate and for each general type of health benefit plan offered by the health carrier on all requests for external review that are filed with the health carrier during a calendar year.
(2) Each health carrier required to maintain written records on all requests for external review pursuant to item (1) shall submit to the director or his designee, no later than March first of each year and upon request by the director or his designee, a report in the format specified by the director or his designee.
(3) The report shall include in the aggregate and by type of health benefit plan:
(a) the total number of requests for external review and the manner in which they were resolved;
(b) the average length of time for resolution;
(c) a summary of the types of coverages or cases for which an external review was sought, as provided in the format required by the director or his designee; and
(d) any other information the director or his designee may request or require.
(4) The health carrier shall retain the written records required pursuant to this subsection for at least three years.
(C) The director or his designee shall make the reports required in this section available to any person for inspection and copying upon request.
HISTORY: 2000 Act No. 380, Section 3A.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-2050. Health carrier to inform covered persons of rights related to external review.

(A) Each health carrier shall include a description of the external review procedures in either the policy, certificate, membership booklet, outline of coverage, or other evidence of coverage it provides to covered persons.
(B) The description required under subsection (A) shall include a statement of the right of the covered person to contact the director or his designee for assistance. The statement shall include the telephone number and address of the director or his designee.
(C) In addition to subsection (B), the statement shall inform the covered person that, when filing a request for an external review, the covered person will be required to authorize the release of any medical records of the covered person that may be required to be reviewed for the purpose of reaching a decision on the external review.
HISTORY: 2000 Act No. 380, Section 3A.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-2110 to 38-71-2150. Repealed.

HISTORY: Former Section 38-71-2110, titled Definitions; application of article, had the following history: 2016 Act No. 163 (S.849), Section 1, eff January 1, 2016. Repealed by 2019 Act No. 48, Section 4, eff January 1, 2021.
HISTORY: Former Section 38-71-2120, titled Placement of drug on maximum allowable cost list, had the following history: 2016 Act No. 163 (S.849), Section 1, eff January 1, 2016. Repealed by 2019 Act No. 48, Section 4, eff January 1, 2021.
HISTORY: Former Section 38-71-2130, titled Duties of pharmacy benefit manager, had the following history: 2016 Act No. 163 (S.849), Section 1, eff January 1, 2016. Repealed by 2019 Act No. 48, Section 4, eff January 1, 2021.
HISTORY: Former Section 38-71-2140, titled Process for appeals, had the following history: 2016 Act No. 163 (S.849), Section 1, eff January 1, 2016. Repealed by 2019 Act No. 48, Section 4, eff January 1, 2021.
HISTORY: Former Section 38-71-2150, titled Prohibited acts, had the following history: 2018 Act No. 177 (H.5038), Section 1, eff May 3, 2018. Repealed by 2019 Act No. 48, Section 4, eff January 1, 2021.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-2210. License requirement for pharmacy benefits managers.

Section effective until January 1, 2024. See, also, Section 38-71-2210 effective January 1, 2024.
(A)(1) A person or organization may not establish or operate as a pharmacy benefits manager in this State for health benefit plans without obtaining a license from the Director of the Department of Insurance.
(2) The director shall prescribe the application for a license to operate in this State as a pharmacy benefits manager and may charge an initial application fee of one thousand dollars and an annual renewal fee of five hundred dollars, provided the pharmacy benefits manager application form must collect the following information:
(a) the name, address, and telephone contact number of the pharmacy benefits manager;
(b) the name and address of the pharmacy benefits manager's agent for service of process in the State;
(c) the name and address of each person with management or control over the pharmacy benefits manager;
(d) the name and address of each person with a beneficial ownership interest in the pharmacy benefits manager;
(e) a signed statement indicating that, to the best of their knowledge, no officer with management or control of the pharmacy benefit manager has been convicted of a felony or has violated any of the requirements of state law applicable to pharmacy benefits managers, or, if the applicant cannot provide such a statement, a signed statement describing the relevant conviction or violation; and
(f) in the case of a pharmacy benefits manager applicant that is a partnership or other unincorporated association, limited liability company, or corporation, and has five or more partners, members, or stockholders:
(i) the applicant shall specify its legal structure and the total number of its partners, members, or stockholders who, directly or indirectly, own, control, hold with the power to vote, or hold proxies representing ten percent or more of the voting securities of any other person; and
(ii) the applicant shall agree that, upon request by the department, it shall furnish the department with information regarding the name, address, usual occupation, and professional qualifications of any other partners, members, or stockholders who, directly or indirectly, own, control, hold with the power to vote, or hold proxies representing ten percent or more of the voting securities of any other person.
(3) An applicant or a pharmacy benefits manager that is licensed to conduct business in the State shall, unless otherwise provided for in this chapter, file a notice describing any material modification of this information.
(B) The director may promulgate regulations establishing the licensing and reporting requirements of pharmacy benefits managers consistent with the provisions of this article.
(C) The fees and penalties assessed pursuant to this article must be retained by the department for the administration of this chapter.
HISTORY: 2019 Act No. 48 (S.359), Section 1, eff January 1, 2021.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-2220. No restrictions or penalties against pharmacy for disclosing certain information.

Section effective until January 1, 2024. See, also, Section 38-71-2220 effective January 1, 2024.
(A) In any participation contracts between pharmacy benefits managers and pharmacists or pharmacies providing prescription drug coverage for health benefit plans, no pharmacy or pharmacist may be prohibited, restricted, or penalized in any way from disclosing to any covered person any health care information that the pharmacy or pharmacist deems appropriate within their scope of practice.
(B) A pharmacy or pharmacist must not be proscribed by a pharmacy benefits manager from discussing information regarding the total cost for pharmacist services for a prescription drug or from selling a more affordable alternative to the insured if a more affordable alternative is available, but a pharmacy benefits manager may proscribe a pharmacy or pharmacist from sharing proprietary or confidential information.
(C) A pharmacy benefits manager contract with a participating pharmacist or pharmacy may not prohibit, restrict, or limit disclosure of information to the director investigating or examining a complaint or conducting a review of a pharmacy benefits manager's compliance with the requirements pursuant to this act. The information or data acquired during an examination or review pursuant to this section is considered proprietary and confidential and is not subject to the South Carolina Freedom of Information Act.
HISTORY: 2019 Act No. 48 (S.359), Section 1, eff January 1, 2021.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-2250. Enforcement of article; penalties.

Section effective until January 1, 2024. See, also, Section 38-71-2250 effective January 1, 2024.
(A) The director shall enforce this article.
(B)(1) The director may examine or audit the books and records of a pharmacy benefits manager providing claims processing services or other prescription drug or device services for a health benefit plan that are relevant to determining if the pharmacy benefits manager is in compliance with this act. The pharmacy benefits manager shall pay the charges incurred in the examination, including the expenses of the director or his designee and the expenses and compensation of his examiners and assistants. The director or his designee promptly shall institute a civil action to recover the expenses of examination against a pharmacy benefits manager which refuses or fails to pay.
(2) The information or data acquired during an examination pursuant to this section is considered proprietary and confidential and is not subject to the South Carolina Freedom of Information Act.
(C) Violations of this article are subject to the penalties provided in Sections 38-2-10 through 38-2-30.
(D) The director may promulgate regulations regarding pharmacy benefits managers that are not inconsistent with this article.
HISTORY: 2019 Act No. 48 (S.359), Section 1, eff January 1, 2021.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-2260. Construction and application.

Section effective until January 1, 2024. See, also, Section 38-71-2260 effective January 1, 2024.
(A) Nothing in this act is intended or may be construed to be in conflict with existing relevant federal law.
(B) This article does not apply to the South Carolina Department of Health and Human Services in the performance of its duties in administering Medicaid under Titles XIX and XXI of the Social Security Act or to the Medicaid managed care organizations under contract with the South Carolina Department of Health and Human Services.
HISTORY: 2019 Act No. 48 (S.359), Section 1, eff January 1, 2021.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-2220. No restrictions or penalties against pharmacy for disclosing certain information.

Section effective January 1, 2024. See, also, Section 38-71-2220 effective until January 1, 2024.
(A) In any participation contracts between pharmacy benefits managers and pharmacists or pharmacies providing prescription drug coverage for health benefit plans, no pharmacy or pharmacist may be prohibited, restricted, or penalized in any way from disclosing to any covered person any health care information that the pharmacy or pharmacist deems appropriate within their scope of practice.
(B) A pharmacy or pharmacist must not be proscribed by a pharmacy benefits manager from discussing information regarding the total cost for pharmacist services for a prescription drug or from selling a more affordable alternative to the insured if a more affordable alternative is available, but a pharmacy benefits manager may proscribe a pharmacy or pharmacist from sharing proprietary or confidential information.
(C) A pharmacy benefits manager contract with a participating pharmacist or pharmacy may not prohibit, restrict, or limit disclosure of information to the director investigating or examining a complaint or conducting a review of a pharmacy benefits manager's compliance with the requirements pursuant to this act. The information or data acquired during an examination or review pursuant to this section is considered proprietary and confidential and is not subject to the South Carolina Freedom of Information Act.
HISTORY: 2019 Act No. 48 (S.359), Section 1, eff January 1, 2021; 2023 Act No. 30 (S.520), Section 2, eff January 1, 2024.
Editor's Note
2023 Act No. 30, Section 7, provides as follows:
"SECTION 7. This act takes effect January 1, 2024, but the recurring examinations by the Department of Insurance provided for in Sections 38-71-2250(B)(1) and 38-71-2340(B)(1) must not begin before January 1, 2025."
Effect of Amendment
2023 Act No. 30, Section 2, reenacted the section with no apparent change.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-2235. Pharmacy benefits managers must exercise good faith and fair dealing; phone number required; sharing information.

Section effective January 1, 2024.
(A) A pharmacy benefits manager must perform its duties to a health benefit plan or health care insurer exercising good faith and fair dealing.
(B) A pharmacy benefits manager must provide during normal business hours a phone number through which a pharmacy or pharmacist can obtain answers within a reasonable time to questions regarding networks, patient benefits, appeals, and other contractual or service issues.
(C) A pharmacy benefits manager may not prohibit a pharmacy services administrative organization or pharmacy from sharing information directly with the department.
HISTORY: 2023 Act No. 30 (S.520), Section 2, eff January 1, 2024.
Editor's Note
2023 Act No. 30, Section 7, provides as follows:
"SECTION 7. This act takes effect January 1, 2024, but the recurring examinations by the Department of Insurance provided for in Sections 38-71-2250(B)(1) and 38-71-2340(B)(1) must not begin before January 1, 2025."
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-2245. Insured's selection of in-network pharmacy; participation of pharmacy or pharmacist in a network; role of pharmacy benefits manager.

Section effective January 1, 2024.
(A)(1) A pharmacy benefits manager may neither limit an insured from selecting an in-network pharmacy or pharmacist of the insured's choice nor deny the right of a pharmacy or pharmacist to participate in a network if the pharmacy or pharmacist meets the requirements for network participation set forth by the pharmacy benefits manager, and the pharmacy or pharmacist agrees to the contract terms, conditions, and rates of reimbursements.
(2) A pharmacy benefits manager may not impose any pharmacy accreditation standards or recertification requirements for network participation that unreasonably exceed state or federal requirements for licensure as a pharmacy in this State unless authorized under this chapter.
(B) Notwithstanding subsection (A), a pharmacy benefits manager may for specialized delivery drugs specify requirements for network participation that:
(1) directly relate to the ability of the pharmacy or pharmacist to store, handle, or deliver a prescription drug in a manner that ensures the quality, integrity, or safety of the drug, its delivery, or its use; or
(2) relate to quality metrics that affect a pharmacy's or pharmacist's ability to participate, provided that the pharmacy benefits manager applies such terms equally to all network participants.
(C) For prescription drugs that qualify as a high-cost prescription drug, subsection (A) of this section does not apply to a pharmacy benefits manager. A high-cost prescription drug is defined as a prescription drug whose current or prior year's annual average wholesale price exceeded 300 percent of the Federal Poverty Level for a single-member household.
(D) A pharmacy benefits manager must provide notification of any changes to all applicable specialized delivery drug lists and high-cost prescription drug lists and must make such lists available on a website and upon request to participating pharmacies. A pharmacy may appeal a classification determination to the Department of Insurance.
(E) The provisions of this section do not apply to the coverage provided to employees, retirees, and their eligible dependents pursuant to Section 1-11-710 by the South Carolina Public Employee Benefit Authority or through its contracted pharmacy benefits manager.
HISTORY: 2023 Act No. 30 (S.520), Section 2, eff January 1, 2024.
Editor's Note
2023 Act No. 30, Section 7, provides as follows:
"SECTION 7. This act takes effect January 1, 2024, but the recurring examinations by the Department of Insurance provided for in Sections 38-71-2250(B)(1) and 38-71-2340(B)(1) must not begin before January 1, 2025."
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-2250. Enforcement of article; penalties.

Section effective January 1, 2024. See, also, Section 38-71-2250 effective until January 1, 2024.
(A) The director shall enforce this article.
(B)(1) As often as the director deems appropriate, but not less frequently than once every five years, the director may examine or audit the books and records of a pharmacy benefits manager providing claims processing services or other prescription drug or device services for a health benefit plan that are relevant to determining if the pharmacy benefits manager is in compliance with this act. The pharmacy benefits manager shall pay the charges incurred in the examination, including the expenses of the director or his designee and the expenses and compensation of his examiners and assistants. The director or his designee promptly shall institute a civil action to recover the expenses of examination against a pharmacy benefits manager which refuses or fails to pay.
(2) The information or data acquired during an examination pursuant to this section is considered proprietary and confidential and is not subject to the South Carolina Freedom of Information Act.
(C) Violations of this article are subject to the penalties provided in Sections 38-2-10 through 38-2-30.
(D) The director may promulgate regulations regarding pharmacy benefits managers that are not inconsistent with this article.
HISTORY: 2019 Act No. 48 (S.359), Section 1, eff January 1, 2021; 2023 Act No. 30 (S.520), Section 2, eff January 1, 2024.
Editor's Note
2023 Act No. 30, Section 7, provides as follows:
"SECTION 7. This act takes effect January 1, 2024, but the recurring examinations by the Department of Insurance provided for in Sections 38-71-2250(B)(1) and 38-71-2340(B)(1) must not begin before January 1, 2025."
Effect of Amendment
2023 Act No. 30, Section 2, in (B)(1), in the first sentence, substituted "As often as the director deems appropriate, but not less frequently than once every five years, the director" for "The director".
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-2260. Construction and application.

Section effective January 1, 2024. See, also, Section 38-71-2260 effective until January 1, 2024.
(A) Nothing in this act is intended or may be construed to be in conflict with existing relevant federal law.
(B) Other than the antisteering provisions contained in Section 38-71-2230(G), this article does not apply to the South Carolina Department of Health and Human Services in the performance of its duties in administering Medicaid under Titles XIX and XXI of the Social Security Act or to the Medicaid-managed care organizations under contract with the South Carolina Department of Health and Human Services.
(C) Notwithstanding the exemption under subsection (B), contracts between the South Carolina Department of Health and Human Services and Medicaid-managed care organizations must include provisions for biannual audits of Medicaid-managed care organizations' pharmacy pricing mechanisms and include limitations on any pharmacy benefits manager contract arrangements that bill the Medicaid program for more than the total price paid to pharmacies for actual claims.
HISTORY: 2019 Act No. 48 (S.359), Section 1, eff January 1, 2021; 2023 Act No. 30 (S.520), Section 2, eff January 1, 2024.
Editor's Note
2023 Act No. 30, Section 7, provides as follows:
"SECTION 7. This act takes effect January 1, 2024, but the recurring examinations by the Department of Insurance provided for in Sections 38-71-2250(B)(1) and 38-71-2340(B)(1) must not begin before January 1, 2025."
Effect of Amendment
2023 Act No. 30, Section 2, in (B), substituted "Other than the antisteering provisions contained in Section 38-71-2230(G), this article" for "This article" and "Medicaid-managed" for "Medicaid managed"; and added (C).
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-2310. Definitions.

Section effective January 1, 2024.
As used in this article:
(1) "Pharmacist" has the same meaning as provided in Section 40-43-30(65).
(2) "Pharmacy" has the same meaning as provided in Section 40-43-30(67).
(3) "Pharmacy services" has the same meaning as provided in Section 38-71-2200(8).
(4) "Pharmacy benefits manager" or "PBM" has the same meaning as provided in Section 38-71-2200(10).
(5) "Pharmacy Services Administrative Organization" (PSAO) means an entity that has contracted with pharmacy clients in the State to conduct business on their behalf with third-party payers or pharmacy benefits managers. PSAOs provide administrative services to pharmacies and negotiate and enter into contracts with third-party payers or pharmacy benefits managers on behalf of pharmacies.
(6) "PSAO-pharmacy contract" means a contractual agreement between a PSAO and a pharmacy by which a PSAO agrees to negotiate with third-party payers or pharmacy benefits managers on behalf of a pharmacy.
HISTORY: 2023 Act No. 30 (S.520), Section 3, eff January 1, 2024.
Editor's Note
2023 Act No. 30, Section 7, provides as follows:
"SECTION 7. This act takes effect January 1, 2024, but the recurring examinations by the Department of Insurance provided for in Sections 38-71-2250(B)(1) and 38-71-2340(B)(1) must not begin before January 1, 2025."