As a provider, if your request to join a payer network in the following markets has been denied, you might have some recourse for appeals.
Any Willing Provider and Freedom of Choice laws restrict the ability of managed care
entities, including pharmacy benefit managers, to selectively contract with providers. The
managed care entities argue this limits their ability to generate cost savings, while proponents of
the laws suggest that such selective contracts limit competition, leading to an increase in
These laws generally require health insurance companies to allow any qualified healthcare provider who is willing to meet the terms and conditions of the insurer’s contract to participate in their networks.
States listed below have some form of Any Willing Provider laws:
Section 27-1-19: The agreement providing coverage to an insured may not exclude assignment of benefits to any provider at the same benefit paid to a contract provider.
Section 27-45-3: Plan Beneficiaries may choose the licensed pharmacist or pharmacy of their choice. Health insurance policies and employee benefit plans may not deny licensed pharmacies or pharmacists the right to participate.
Sections 23-201, 23-202, 23-203, 23-204, 23-205, 23-206, 23-207, 23-208, 23-209 : Benefit differentials are prohibited. Insurers must give qualified health care providers the opportunity to participate if providers are willing to accept the plan’s terms and conditions.
Section 10-16-122: Any PBM/intermediary whose contract with a carrier includes an open network must allow all area pharmacy providers to participate if they agree to the terms and conditions of the contract. PBms/Intermediaries may contract with exclusive pharmacy networks if a 60-day notice is given before the termination or the effective date of such contract by publication in a newspaper of general circulation.
Section 38a-471: A prescription program administrator shall allow a pharmacy to enroll in a program absent cause for excluding it.
Sections 18-7301, 18-7302, 18-7303: Beneficiaries may choose any pharmacy that has agreed to participate according to the terms. Benefit differentials are prohibited.
Section 110.12315: The state employees’ prescription drug program requires the Department of Management services to allow prescriptions to be filled by any licensed pharmacy pursuant to contractual claims processing provisions.
Section 440.13(3) (j): The worker’s compensation statute allows for a sick or injured employee to have free, full and absolute choice in the selection of the pharmacy.
Section 26-2-144(a)(9): That at least 30 days prior to the date a program becomes effective, the program contract therefor shall be offered to all pharmacies located within those counties wherein reside enrollees in that program, which pharmacies shall have at least 30 days from the time they receive the offer to accept that offer and become participating pharmacies.
Section 33-30-25: Insurers may impose “reasonable limits” on the number/classes of preferred providers that meet the insurers’ standards. Insurers must give all licensed and qualified providers within a defined service are the opportunity to become a preferred provider.
Section 33-30-4.3: Beneficiaries who do not use mail-order shall not be penalized if the provider used by the insured has agreed to the same terms and conditions applicable to mail-order and has agreed to accept payment or reimbursement at no more than the same amount that would be paid for the same mail-order services.
Section 451 R-1: It shall be a violation of this section for a prescription drug benefit plan, health benefits plan under chapter 87A, or pharmacy benefit manager to refuse to accept an otherwise qualified retail community pharmacy as part of a pharmacy benefit manager’s retail pharmacy network.
Sections 41-2872 & 41-3927: Any insurance company or health maintenance organization issuing benefits must be willing to contract with qualified providers who meet the terms of the organization. Organizations issuing benefits must be willing to contract with qualified providers who meet the terms of the organization
Section 215-5/370h: Insurers/administrators must be willing to enter into agreements with any non- institutional providers who meet the established terms and conditions. The terms and conditions may not discriminate unreasonably against or among non-institutional providers.
Section 215-134/72(a) : A plan may not refuse to contract with a pharmacy provider that meets the terms and conditions established by the plan.
Section 27-8-11-3 : Pharmacists who agree to comply with established terms and conditions
are entitled to enter into contracts with insurers. Terms and conditions established by insurers may not discriminate unreasonably against or among providers.
Section 514C.5: Policies or contracts providing for third-party payment may not require a beneficiary to order prescriptions by mail if the pharmacy chosen by the beneficiary agrees to comply with the same terms and conditions as the mail-order pharmacy.
Section 304.17A-270: A health insurer shall not discriminate against any provider who is located within the geographic coverage area of the plan and who is willing to meet the terms and conditions for participation established by the plan, including the Kentucky State Medicaid program and Medicaid partnerships.
Section 304.17A-505: …if the provider meets the insurer’s enrollment criteria and is willing to meet the terms and conditions for
participation, the provider has the right to become a provider for the insurer.
Section: 22:1964: Policies/plans must allow beneficiaries to select the pharmacy/pharmacist of their choice as long as the chosen pharmacy agrees to meet the terms and conditions of the plan.
Pharmacies that agree to meet the established terms and conditions have the right to participate as contract providers. Renamed from Section 22:1214(15).
Section 22:2181: The Louisiana State University Health Sciences Center Health Maintenance Organization shall enter into a contract with any willing provider licensed by the Louisiana State Board of Medical Examiners or the Louisiana State Board of Dental Examiners to provide primary care services delivered in an outpatient setting including medical and surgical services.
24-A M.R.S.A. § 4317: insurance carriers offering health plans subject to the Maine Health Plan Improvement Act that provide prescription drug benefits through a network of participating pharmacies may not refuse to contract with a pharmacy that is willing to meet the terms and conditions for participation in the health plan’s pharmacy network. If the network is a tiered network, Maine pharmacies must be offered the opportunity to participate in each tier. A pharmacy benefits manager may not require a pharmacist or pharmacy to participate in one network in order to participate in another network. The pharmacy benefits manager may not exclude an otherwise qualified pharmacist or pharmacy from participation in one network solely because the pharmacist or pharmacy declined to participate in another network managed by the pharmacy benefits manager.
Section 176D(3B): Carriers who offer restricted pharmacy networks must follow certain requirements in contracting. Carriers must neither exclude nor favor individual pharmacies and must not impose greater restrictions on non-network pharmacies than those required on in-network pharmacies.
Section 83-9-6: Beneficiaries may choose any pharmacy that has agreed to participate in the plan according to the insurer’s terms. Pharmacies that accept those terms are entitled to participate.
Benefit differentials are prohibited. Plans that restrict pharmacy participation shall give 60 days notice of offer to participate to all pharmacies in the geographic area.
Section 354.535: Every Health maintenance organization has to apply the same coinsurance, co- payment and deductible factors to all prescriptions filled by a pharmacy provider who participates in the network if the provider meets the contact’s product cost determination. Also HMOs may not set a limit on the quantity of drugs which an enrollee may obtain at any one time with a prescription unless such limit is applied uniformly to all pharmacy providers in the network.
Section 33-22-1704: A preferred provider agreement must provide all providers with the opportunity to participate on the basis of a competitive bid.
Section 44-513.02: Beneficiaries shall not be required to obtain pharmaceutical services from mail- order in order to obtain reimbursement.
Section 44-313(2) :…an insurer may contract with a licensed pharmacist for pharmacist professional
services. Nothing in this section shall prohibit an insurer from contracting with a licensed pharmacist who is not employed or associated with a pharmacy. Nothing in this section shall require a licensed pharmacist to contract with an insurer for pharmacist professional services.
Section 420-B:12(V): HMOs seeking bids from pharmacies for agreements to be preferred providers must admit and list all pharmacies that meet the bid.
Sections 17:48-6j & 26:2J-4.7: An enrollee/subscriber shall be permitted to select a pharmacy/pharmacist provided the pharmacist or pharmacy is registered. Pharmacies/pharmacists shall have the right to participate as preferred providers if the agreement provides for coverage by preferred providers, so long as the pharmacy/pharmacist complies with the terms of the agreement. Benefit differentials shall not be imposed. Enrollees/subscribers shall not be required to use a mail- order pharmacy.
Section126.96.36.199(f): “Point of care vendor” means an entity contracted with a prescriber to generate or transmit electronic prescriptions authorized by a practitioner directly to a pharmacy or to a “contracted” intermediary or “network vendor”, who will ultimately transmit the prescription order to a patient’s pharmacy of choice. Vendor must provide an unbiased listing of provider pharmacies and not use
pop-ups or other paid advertisements to influence the prescriber’s choice of therapy or to interfere with patient’s freedom of choice of pharmacy. Presentation of drug formulary information, including preferred and non-preferred drugs and co-pay information if available, is allowed.
Section 58-51-37: Beneficiaries may choose any pharmacy that has agreed to participate according to the insurer’s terms. Pharmacies that accept such terms are entitled to participate and must participate if offered the opportunity. Benefit differentials are prohibited. Plans that limit pharmacy participation shall give 60 days notice of an offer to participate to all pharmacies in the geographic area.
Section 26.1-36-12.2: Beneficiaries may choose any licensed pharmacy/pharmacist to provide services. Benefit differentials are prohibited. Licensed pharmacists who accept the terms may participate in the plan.
Section 36-3634.3 & 36-4511: Pharmacies must be provided the right to bid on a periodic basis on any pharmacy contract to provider pharmacy services. Employers may not require employees to obtain drugs from a mail-order pharmacy as a condition for reimbursement. Employers may not impose benefit differentials if they do not use mail-order.
Title 15 § 15-788(c): No third party prescription program administrator shall deny any pharmacy the opportunity to participate in any third party prescription program offered in this state in a manner which will restrain the right of a consumer to select a pharmacy.
RI Gen. Laws 27-29-1: Unfair competition and practices.
Section 38-71-147: No individual or group accident and health or health insurance policy or HMO may prohibit a participant/beneficiary from selecting pharmacies/pharmacists that agreed to participate in the plan according to the terms of the insurer, or may deny pharmacies/pharmacists the right to participate as contract providers if they agree to insurer’s terms and conditions.
Section 58-18-37: Group health insurance policies may not refuse to accept licensed pharmacies/pharmacists as participating providers if they agree to the same terms and conditions offered to other providers of pharmacy services under the policy.
Section 56-7-117: Group medical benefit contracts covering prescriptions may not require a covered person to obtain prescriptions from mail-order, or to pay an additional fee, or be subjected to a penalty for declining to use a designated mail-order pharmacy.
Section 56-7-2359: Licensed pharmacies may not be denied right to participate on the same terms and conditions offered other participants; benefit differentials are prohibited.
Section 21.52B 2(a) (2): A pharmacy/pharmacist may not be denied the right to participate as a contract provider under the plan if the pharmacy/pharmacist agrees to provide pharmaceutical services that meet all terms and requirements and to include the same administrative, financial, and professional conditions that apply to pharmacies/pharmacists that have been designated as providers under plan.
Section 31A-22-617: Insurers must allow providers to apply for and be designated as preferred providers if they agree to meet established terms and conditions. “Reasonable limitations” may be placed on the number of designated preferred providers.
Section 38.2-3407: Insurers shall establish terms and conditions in order to receive payment as a preferred provider. The terms and conditions shall not discriminate unreasonably against or among such health care providers and cannot exclude any provider willing to meet the terms and conditions.
Section 38.2-3407.7: Insurers shall not prohibit any person receiving pharmacy benefits from selecting, without limitation, the pharmacy of his choice.
Section 38.2-4209: Providers who are willing to accept established terms and conditions may qualify for payment under preferred provider contracts.
Section 38.2-4209.1: Corporations must allow beneficiaries to select the pharmacy of their choice if pharmacies that are non-preferred providers have previously notified the corporation of their agreement to accept reimbursement at rates applicable to preferred providers.
Section 38.2-4312.1: No Health maintenance organization shall prohibit any person receiving pharmaceutical benefits from selecting, without limitation, the pharmacy of his choice. No monetary penalty which would affect or influence any person’s choice of pharmacy shall be imposed.
Section 628.36 (2m): An annual 30-day open enrollment period during which any pharmacist may elect to participate is required.
Section 26-22-503: Any provider willing to meet the established requirements has the right to enter into contracts relating to health care services.
Section 26-34-134: Providers willing to meet an HMO’s established terms shall not be denied the right to contract. An HMO may not discriminate against a provider on the basis of the provider’s academic degree.
Please note that laws can change over time, so it’s always a good idea to verify the current status of AWP laws in specific states if you need the most up-to-date information.