§ 33-22-173 — Maximum Allowable Cost -- Appeals Process

33-22-173 . Maximum allowable cost -- appeals process. (1) In contracting with a pharmacy or a pharmacy services administrative organization, a plan sponsor or pharmacy benefit manager shall:
(a) provide a procedure by which a pharmacy or a pharmacy services administrative organization may appeal the price of a drug or drugs on the maximum allowable cost list;
(b) provide a telephone number at which a network pharmacy may contact the pharmacy benefit manager to discuss the status of the pharmacy's appeal; and
(c) respond to an appeal no later than 10 calendar days after the date the appeal is made.
(2) If the final determination is a denial of the pharmacy's or the pharmacy services administrative organization's appeal, the pharmacy benefit manager shall state the reason for the denial and provide the national drug code of an equivalent drug that is available for purchase by pharmacies in this state from national or regional wholesalers at a price that is equal to or less than the maximum allowable cost for that drug.
(3) If a pharmacy's or a pharmacy services administrative organization's appeal is determined to be valid by the pharmacy benefit manager, the pharmacy benefit manager shall:
(a) make an adjustment in the drug price effective on the date the appeal is resolved;
(b) make the adjustment applicable to all similarly situated network pharmacy providers as determined by the plan sponsor or the pharmacy benefit manager, as appropriate; and
(c) permit the appealing pharmacy to reverse and rebill the claim in question, using the dates of the original claim or claims.
(4) A pharmacy benefit manager shall make price adjustments to all similarly situated pharmacies within 3 days.
(5) A pharmacy or a pharmacy services administrative organization shall file its appeal within 10 calendar days from the time of denial by the pharmacy benefit manager.

Legislative History

En. Sec. 4, Ch. 431, L. 2015; amd. Sec. 25, Ch. 157, L. 2023.