§ 27-1-24.5-25 — Contract holder's right to audit; disclosure of data; amounts paid; consideration

Indiana § 27-1-24.5-25

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

Text

Note: This version of section effective until 7-1-2025. See also
following version of this section, effective 7-1-2025.
Sec. 25. (a) A contract holder may, one (1) time in
a calendar year and not earlier than six (6) months following a
previously requested audit, request an audit of compliance with the
contract. If requested by the contract holder, the audit shall include full
disclosure of the following data specific to the contract holder:
(1) Rebate amounts secured on prescription drugs, whether
product specific or general rebates, that were provided by a
pharmaceutical manufacturer. The information provided under
this subdivision must identify the prescription drugs by
therapeutic category.
(2) Pharmaceutical and device claims received by the pharmacy
benefit manager on any of the following:
(A) The CMS-1500 form or its successor form.
(B) The HCFA-1500 form or its successor form.
(C) The HIPAA X12 837P electronic claims transaction for
professional services, or its successor transaction.
(D) The HIPAA X12 837I institutional form or its successor
form.
(E) The CMS-1450 form or its successor form.
(F) The UB-04 form or its successor form.
The forms or transaction may be modified as necessary to comply
with the federal Health Insurance Portability and Accountability
Act (HIPAA) (P.L. 104-191) or to redact a trade secret (as defined
in IC 24-2-3-2).
(3) Pharmaceutical and device claims payments or electronic
funds transfer or remittance advice notices provided by the
pharmacy benefit manager as ASC X12N 835 files or a successor
format. The files may be modified as necessary to comply with
the federal Health Insurance Portability and Accountability Act
(HIPAA) (P.L. 104-191) or to redact a trade secret (as defined in
IC 24-2-3-2). In the event that paper claims are provided, the
pharmacy benefit manager shall convert the paper claims to the
ASC X12N 835 electronic format or a successor format.
(4) Any other revenue and fees derived by the pharmacy benefit
manager from the contract, including all direct and indirect
remuneration from pharmaceutical manufacturers regardless of
whether the remuneration is classified as a rebate, fee, or another
term.
(b) A pharmacy benefit manager may not impose the following:
(1) Fees for:
(A) requesting an audit under this section; or
(B) selecting an auditor other than an auditor designated by the
pharmacy benefit manager.
(2) Conditions that would restrict a contract holder's right to
conduct an audit under this section, including restrictions on the:
(A) time period of the audit;
(B) number of claims analyzed;
(C) type of analysis conducted;
(D) data elements used in the analysis; or
(E) selection of an auditor as long as the auditor:
(i) does not have a conflict of interest;
(ii) meets a threshold for liability insurance specified in the
contract between the parties;
(iii) does not work on a contingent fee basis; and
(iv) does not have a history of breaching nondisclosure
agreements.
(c) A pharmacy benefit manager shall disclose, upon request from
a contract holder, to the contract holder the actual amounts directly or
indirectly paid by the pharmacy benefit manager to the pharmacist or
pharmacy for the drug and for pharmacist services related to the drug.
(d) A pharmacy benefit manager shall provide notice to a contract
holder contracting with the pharmacy benefit manager of any
consideration, including direct or indirect remuneration, that the
pharmacy benefit manager receives from a pharmaceutical
manufacturer or group purchasing organization for formulary
placement or any other reason.
(e) The commissioner may establish a procedure to release
information from an audit performed by the department to a contract
holder that has requested an audit under this section in a manner that
does not violate confidential or proprietary information laws.
(f) A contract that is entered into, issued, amended, or renewed after
June 30, 2024, may not contain a provision that violates this section.
(g) A pharmacy benefit manager shall:
(1) obtain any information requested in an audit under this section
from a group purchasing organization or other partner entity of
the pharmacy benefit manager; and
(2) provide claims data to the contract holder not later than fifteen
(15) business days after the information or claims data is
requested.
(h) Information provided in an audit under this section must be
provided in accordance with the federal Health Insurance Portability
and Accountability Act (HIPAA) (P.L. 104-191).

Legislative History

As added by P.L.68-2020, SEC.1. Amended by P.L.32-2021, SEC.81; P.L.152-2024, SEC.12; P.L.216-2025, SEC.40.