This text of Iowa § 510B.8E (Appeals and disputes) is published on Counsel Stack Legal Research, covering Iowa primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.
1.A pharmacy benefits manager shall provide a reasonable process to allow a pharmacy
to appeal any matter.
2.The appeals process must include all of the following:
§510B.8E, REGULATION OF PHARMACY BENEFITS MANAGERS 8
a.Adedicatedtelephonenumberatwhichapharmacymaycontactthepharmacybenefits
manager and speak directly with an individual who is involved with the appeals process.
b.A dedicated electronic mail address or internet site for the purpose of submitting an
appeal directly to the pharmacy benefits manager.
c.A period of no less than thirty business days after the date of a pharmacy’s initial
submission of a clean claim during which the pharmacy may initiate an appeal.
3.The pharmacy benefits manager shall respond to an appeal within seven business days
after the date on which the
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1. A pharmacy benefits manager shall provide a reasonable process to allow a pharmacy
to appeal any matter.
2. The appeals process must include all of the following:
§510B.8E, REGULATION OF PHARMACY BENEFITS MANAGERS 8
a. Adedicatedtelephonenumberatwhichapharmacymaycontactthepharmacybenefits
manager and speak directly with an individual who is involved with the appeals process.
b. A dedicated electronic mail address or internet site for the purpose of submitting an
appeal directly to the pharmacy benefits manager.
c. A period of no less than thirty business days after the date of a pharmacy’s initial
submission of a clean claim during which the pharmacy may initiate an appeal.
3. The pharmacy benefits manager shall respond to an appeal within seven business days
after the date on which the pharmacy benefits manager receives the appeal.
a. If the pharmacy benefits manager grants a pharmacy’s appeal related to a
reimbursement rate, the pharmacy benefits manager shall do all of the following:
(1) Adjustthereimbursementrateoftheprescriptiondrugthatisthesubjectoftheappeal
and provide the national drug code number that the adjustment is based on to the appealing
pharmacy.
(2) Reverse and resubmit the claim that is the subject of the appeal.
(3) Make the adjustment pursuant to subparagraph (1) applicable to all of the following:
(a) Each pharmacy that is under common ownership with the pharmacy that submitted
the appeal.
(b) Eachpharmacyinthestatethatdemonstratestheinabilitytopurchasetheprescription
drug for less than the established reimbursement rate.
b. If the pharmacy benefits manager denies a pharmacy’s appeal, the pharmacy benefits
manager shall do all of the following:
(1) Provide the appealing pharmacy the national drug code number and the name of a
wholesale distributor licensed pursuant to section 155A.17 from which the pharmacy can
obtain the prescription drug at or below the reimbursement rate.
(2) If the prescription drug identified by the national drug code number provided
by the pharmacy benefits manager pursuant to subparagraph (1) is not available below
the pharmacy acquisition cost from the wholesale distributor from whom the pharmacy
purchases the majority of its prescription drugs for resale, the pharmacy benefits manager
shall adjust the reimbursement rate above the appealing pharmacy’s pharmacy acquisition
cost, and reverse and resubmit each claim affected by the pharmacy’s inability to procure
the prescription drug at a cost that is equal to or less than the previously appealed
reimbursement rate.