§ 27-1-24.5-22 — Required information; appeals process; auditing procedures

Indiana § 27-1-24.5-22

• Jurisdiction: Indiana
• Title 27: INSURANCE
• Art. 1: DEPARTMENT OF INSURANCE
• Ch. 24.5: Pharmacy Benefit Managers

Text

(a) A pharmacy benefit manager shall do
the following:
(1) Identify to contracted:
(A) pharmacy services administrative organizations; or
(B) pharmacies if the pharmacy benefit manager contracts
directly with pharmacies;
the sources used by the pharmacy benefit manager to calculate the
drug product reimbursement paid for covered drugs available
under the pharmacy health plan administered by the pharmacy
benefit manager.
(2) Establish an appeal process for contracted pharmacies,
pharmacy services administrative organizations, or group
purchasing organizations to appeal and resolve disputes
concerning the maximum allowable cost pricing.
(3) Update and make available to pharmacies:
(A) at least every seven (7) days; or
(B) in a different time frame if contracted between a pharmacy
benefit manager and a pharmacy;
the pharmacy benefit manager's maximum allowable cost list.
(4) Determine that a prescription drug:
(A) is not obsolete;
(B) is generally available for purchase by pharmacies in Indiana
from a national or regional wholesaler licensed in Indiana; and
(C) is not:
(i) temporarily unavailable;
(ii) listed on a drug shortage list; or
(iii) unable to be lawfully substituted;
before the prescription drug is placed or continued on a maximum
allowable cost list.
(b) The appeal process required by subsection (a)(2) must include
the following:
(1) The right to appeal a claim not to exceed sixty (60) days
following the initial filing of the claim.
(2) The investigation and resolution of a filed appeal by the
pharmacy benefit manager in a time frame determined by the
commissioner.
(3) If an appeal is denied, a requirement that the pharmacy benefit
manager do the following:
(A) Provide the reason for the denial.
(B) Provide the appealing contracted pharmacy, pharmacy
services administrative organization, or group purchasing
organization with the national drug code number of the
prescription drug that is available from a national or regional
wholesaler operating in Indiana.
(4) If an appeal is approved, a requirement that the pharmacy
benefit manager do the following:
(A) Change the maximum allowable cost of the drug for the
pharmacy that filed the appeal as of the initial date of service
that the appealed drug was dispensed.
(B) Adjust the maximum allowable cost of the drug for the
appealing pharmacy and for all other contracted pharmacies in
the same network of the pharmacy benefit manager that filled
a prescription for patients covered under the same health plan
beginning on the initial date of service the appealed drug was
dispensed.
(C) Notify each pharmacy in the pharmacy benefit manager's
network that the maximum allowable cost for the drug has been
adjusted as a result of an approved appeal.
(D) Adjust the drug product reimbursement for contracted
pharmacies that resubmit claims to reflect the adjusted
maximum allowable cost, if applicable.
(E) Allow the appealing pharmacy and all other contracted
pharmacies in the network that filled the prescriptions for
patients covered under the same health plan to reverse and
resubmit claims and receive payment based on the adjusted
maximum allowable cost from the initial date of service the
appealed drug was dispensed.
(F) Make retroactive price adjustments in the next payment
cycle unless otherwise agreed to by the pharmacy.
(5) The establishment of procedures for auditing submitted claims
by a contracted pharmacy in a manner established by
administrative rules under IC 4-22-2 by the department. The
auditing procedures:
(A) may not use extrapolation or any similar methodology;
(B) may not allow for recovery by a pharmacy benefit manager
of a submitted claim due to clerical or other error where the
patient has received the drug for which the claim was
submitted;
(C) must allow for recovery by a contracted pharmacy for
underpayments by the pharmacy benefit manager; and
(D) may only allow for the pharmacy benefit manager to
recover overpayments on claims that are actually audited and
discovered to include a recoverable error.
(c) The department must approve the manner in which a pharmacy
benefit manager may respond to an appeal filed under this section. The
department shall establish a process for a pharmacy benefit manager to
obtain approval from the department under this section.

Legislative History

As added by P.L.68-2020, SEC.1. Amended by P.L.32-2021, SEC.79; P.L.196-2021, SEC.24.