This text of Montana § 33-22-172 (Maximum Allowable Cost Or Reference Price List -- Price Formulation, Updating, And Disclosure -- Exceptions) is published on Counsel Stack Legal Research, covering Montana primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.
33-22-172 . (Temporary) Maximum allowable cost or reference price list -- price formulation, updating, and disclosure -- exceptions.
(1)At the time of entering into a contract with a pharmacy or a pharmacy services administrative organization and subsequently upon request, a plan sponsor, health insurance issuer, or pharmacy benefit manager shall provide the pharmacy or pharmacy services administrative organization with the sources used to determine the pricing for the maximum allowable cost list or the reference used for reference pricing.
(2)If using a maximum allowable cost list, a plan sponsor, health insurance issuer, or pharmacy benefit manager shall:
(a)review and update the price information for each drug on the maximum allowable cost list at least once every 10 calendar days to
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33-22-172 . (Temporary) Maximum allowable cost or reference price list -- price formulation, updating, and disclosure -- exceptions. (1) At the time of entering into a contract with a pharmacy or a pharmacy services administrative organization and subsequently upon request, a plan sponsor, health insurance issuer, or pharmacy benefit manager shall provide the pharmacy or pharmacy services administrative organization with the sources used to determine the pricing for the maximum allowable cost list or the reference used for reference pricing.
(2) If using a maximum allowable cost list, a plan sponsor, health insurance issuer, or pharmacy benefit manager shall:
(a) review and update the price information for each drug on the maximum allowable cost list at least once every 10 calendar days to reflect any modification of pricing, ensuring that maximum allowable cost increases are processed and updated on the same schedule as decreases;
(b) establish a process for eliminating products from the maximum allowable cost list or modifying the prices in the maximum allowable cost list in a timely manner to remain consistent with pricing changes and product availability in the marketplace; and
(c) provide a process for each pharmacy to readily access the maximum allowable cost list specific to the pharmacy in a searchable and usable format.
(3) If using reference pricing, a plan sponsor, health insurance issuer, or pharmacy benefit manager shall:
(a) review and update not less than every 10 business days the price information for each drug, product, supply, or service for which reference pricing is used, updating reference pricing on the same date of the change in the referenced source; and
(b) provide a process for each pharmacy to readily access the reference pricing specific to the plan sponsor or the health insurance issuer's plan.
(4) A plan sponsor, health insurance issuer, or pharmacy benefit manager may not:
(a) prohibit a pharmacist from discussing reimbursement criteria with a covered person;
(b) penalize a pharmacy or a pharmacist for disclosing the information described in subsection (4)(a) to a covered person or for selling a more affordable alternative to a covered person; or
(c) require a pharmacy to charge or collect a copayment from a covered person that exceeds the total charges submitted by the network pharmacy.
(5) (a) A plan sponsor, pharmacy benefits manager, or third-party payer shall ensure that reimbursement to independent pharmacies for each drug dispensed is not less than the national average drug acquisition cost plus a professional dispensing fee that is not less than the minimum specified in this subsection (5). The national average drug acquisition cost price must be the price published in effect for the day the drug claim was billed by the pharmacy.
(b) In the event that a particular drug does not have a published national average drug acquisition price, the reimbursement to independent pharmacies must be:
(i) for generic drugs, 100% of published wholesale acquisition costs plus a professional dispensing fee that is not less than the minimum specified in this subsection (5); and
(ii) for brand-name drugs, 100% of wholesale acquisition costs plus a professional dispensing fee that is not less than the minimum specified in this subsection (5).
(c) The minimum professional dispensing fee for independent pharmacies is $15, subject to an annual increase. On January 1 of each year, a plan sponsor, pharmacy benefits manager, or third-party payer shall increase the amount of the minimum professional dispensing fee for independent pharmacies for inflation. Inflation is measured by the annual percentage increase, if any, in the consumer price index, U.S. city average, all urban consumers, for all items, as published by the bureau of labor statistics of the United States department of labor.
(d) This subsection (5) does not apply to reimbursements to pharmacies under Title 39, chapter 71. (Terminates June 30, 2029--sec. 8, Ch. 474, L. 2025.)