§1868. Local pharmacy reimbursement; National Average Drug Acquisition Costs; appeals
A. No pharmacy benefit manager or person acting on behalf of a pharmacy benefit
manager shall reimburse a pharmacy or pharmacist in this state an amount less than the
acquisition cost for the covered drug, device, or service. The provisions of this Section shall
apply only to reimbursement for a contracted pharmacist or local pharmacy.
B. For purposes of this Section, the following definitions shall apply:
(1)"Acquisition cost" means the set of National Average Drug Acquisition Costs,
"NADAC", as calculated by the Centers for Medicare and Medicaid Services and reflected
in the most recently released public file.
(2)"Adjustment factor" means a percentage-based change to the prescription drug
pricing benc
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§1868. Local pharmacy reimbursement; National Average Drug Acquisition Costs; appeals
A. No pharmacy benefit manager or person acting on behalf of a pharmacy benefit
manager shall reimburse a pharmacy or pharmacist in this state an amount less than the
acquisition cost for the covered drug, device, or service. The provisions of this Section shall
apply only to reimbursement for a contracted pharmacist or local pharmacy.
B. For purposes of this Section, the following definitions shall apply:
(1) "Acquisition cost" means the set of National Average Drug Acquisition Costs,
"NADAC", as calculated by the Centers for Medicare and Medicaid Services and reflected
in the most recently released public file.
(2) "Adjustment factor" means a percentage-based change to the prescription drug
pricing benchmark, such as average wholesale price or national average drug acquisition
cost, applied uniformly across a class of drugs.
(3) "Claim payment error" means a pharmacy or pharmacist claim payment amount
that fails to reimburse at or above acquisition cost.
(4) "Reimbursement formula" means a prescription drug reimbursement calculation
involving an ingredient price, calculated based on a prescription drug pricing benchmark plus
an adjustment factor, and a professional dispensing fee.
C. Notwithstanding any provision of law to the contrary, effective January 1, 2026,
a pharmacy benefit manager shall meet all of the following requirements for claims
submitted by any local pharmacy to a pharmacy benefit manager administering claims on
behalf of a health plan, except for the Office of Group Benefits:
(1) Adopt a reimbursement formula using either NADAC as the prescription drug
pricing benchmark or, with prior written approval by the commissioner, an alternative
prescription drug pricing benchmark that results in claim payment errors that are both
comparable to or less than NADAC in terms of frequency and smaller than NADAC in terms
of magnitude.
(2) Adopt a reimbursement formula using an adjustment factor that, based on claims
experience data available to the pharmacy benefit manager, is reasonably expected to result
in a claim payment error rate of no more than two percent per drug as identified by its
national drug code.
(3) Adopt an appeal process for pharmacists to challenge claim payment errors that,
at a minimum, meets the following requirements:
(a) A network pharmacy contract executed by and between a pharmacy benefit
manager and a pharmacy located in Louisiana shall, at a minimum, contain a provision
expressly acknowledging that if a Louisiana pharmacy's reimbursement for any covered drug
or device is less than the pharmacy's acquisition cost for that drug or device, the pharmacy
has the right to appeal that reimbursement and, if successful, receive additional payment so
that the total reimbursement is equal to the pharmacy's demonstrated acquisition cost. The
pharmacy benefit manager shall direct the pharmacy to the pharmacy benefit manager's
electronic and written appeal locations.
(b) Permit appeals to be filed for a period of fifteen days following the applicable
date of payment.
(c) If an appeal is filed with the pharmacy benefit manager, the pharmacy must
include a written invoice from the wholesaler that includes the drug name, national drug code
number, purchase date, and cost of the drug.
(d) If a claim payment error occurred, the pharmacy benefit manager shall make an
additional payment to the pharmacy to increase the reimbursement amount to the acquisition
cost.
(e) The pharmacy benefit manager shall individually notify all pharmacies using the
same customary supplier or wholesaler that a claim payment error occurred and that the
pharmacy may reverse and resubmit the claim to correct the claim payment error. The
pharmacy benefit manager shall make retroactive price adjustments in the next payment
cycle.
(f) If a pharmacy benefit manager determines that a claim payment error did not
occur, it shall provide the pharmacy or pharmacist with an explanation of why it has upheld
the payment, including a specific documentation of the acquisition cost on the date of
service. The explanation shall be provided electronically or in writing through customary
means of communication between the pharmacy benefit manager and the pharmacy or
pharmacist. The explanation shall also include a notice in at least ten-point font stating that,
if the pharmacy or pharmacist disagrees with the decision, the pharmacy or pharmacist may
file a complaint with the Department of Insurance.