§ 27-1-24.2-15 — Required provisions in a contract between a pharmacy or pharmacist and a pharmacy benefit manager; prohibition on requesting a refund or making a recoupment of a dispensing fee if the correct medication was dispensed

Indiana § 27-1-24.2-15

• Jurisdiction: Indiana
• Title 27: INSURANCE
• Art. 1: DEPARTMENT OF INSURANCE
• Ch. 24.2: Pharmacy Benefits

Text

Effective 1-1-2026.
Sec. 15. (a) A contract between a pharmacy or
pharmacist and an insurer, a pharmacy benefit manager, or any other
administrator of pharmacy benefits for the provision of pharmacy or
pharmacist services under a health plan, either directly or through a
pharmacy services administrative organization or group purchasing
organization, must include provisions that do the following:
(1) Outline the terms and conditions for the provision of
pharmacy or pharmacist services.
(2) Subject to subsection (b), prohibit the insurer, pharmacy
benefit manager, or other administrator from retroactively
denying, reducing reimbursement for, or seeking any refunds or
recoupments for a claim for pharmacy or pharmacist services, in
whole or in part, from the pharmacy or pharmacist after returning
a paid claim response as part of the adjudication of the claim,
including claims for the cost of a medication or dispensed product
and claims for pharmacy or pharmacist services that are deemed
ineligible for coverage, unless:
(A) the original claim was submitted fraudulently; or
(B) the pharmacy or pharmacist received an actual
overpayment.
(3) Prohibit the insurer, pharmacy benefit manager, or other
administrator from reimbursing the pharmacy or pharmacist for
a prescription drug or other service at a net amount that is less
than the greater of the following:
(A) The amount the insurer, pharmacy benefit manager, or
other administrator reimburses itself or a pharmacy affiliate for
the same prescription drug by national drug code number or
service.
(B) The following amount, as applicable:
(i) If the prescription drug or service is administered,
dispensed, or provided at a pharmacy that is a licensed
premises (as defined in IC 7.1-1-3-20), the actual acquisition
cost for the prescription drug or service plus a fair and
reasonable dispensing fee.
(ii) If the prescription drug or service is administered,
dispensed, or provided at a pharmacy not described in item
(i), the national average drug acquisition cost (NADAC) for
the prescription drug or service, as determined by the federal
Centers for Medicare and Medicaid Services at the time the
prescription drug or service is administered, dispensed, or
provided plus a professional dispensing fee equal to the
Medicaid fee for service dispensing fee under 405 IAC
5-24-6.
(b) An insurer, a pharmacy benefit manager, or any other
administrator of pharmacy benefits may not request a refund or make
a recoupment of a dispensing fee paid to the pharmacy if the correct
medication was dispensed to the patient.

Legislative History

As added by P.L.189-2025, SEC.1.