This text of North Dakota § 19-02.1-14.2 (Maximum allowable cost lists for pharmaceuticals - Pharmacy benefits managers - Penalty) is published on Counsel Stack Legal Research, covering North Dakota primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.
managers - Penalty.
1.For the purposes of this section:
a."Determination" means a decision that settles and ends a controversy or the
resolution of a question through appeal.
b."Maximum allowable cost price" means a maximum reimbursement amount for a
group of therapeutically equivalent and pharmaceutically equivalent multiple
source drugs.
c."Multiple source drug" means a therapeutically equivalent drug that is available
from at least two manufacturers.
d."Pharmacy benefits manager" has the same meaning as in section 19-03.6-01.
2.With respect to each contract between a pharmacy benefits manager and a pharmacy,
each pharmacy benefits manager shall:
a.Provide to the pharmacy, at the beginning of each contract and contract renewal,
the sources utilized to determine the maximum allowa
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managers - Penalty.
1. For the purposes of this section:
a. "Determination" means a decision that settles and ends a controversy or the
resolution of a question through appeal.
b. "Maximum allowable cost price" means a maximum reimbursement amount for a
group of therapeutically equivalent and pharmaceutically equivalent multiple
source drugs.
c. "Multiple source drug" means a therapeutically equivalent drug that is available
from at least two manufacturers.
d. "Pharmacy benefits manager" has the same meaning as in section 19-03.6-01.
2. With respect to each contract between a pharmacy benefits manager and a pharmacy,
each pharmacy benefits manager shall:
a. Provide to the pharmacy, at the beginning of each contract and contract renewal,
the sources utilized to determine the maximum allowable cost pricing of the
pharmacy benefits manager.
b. Update any maximum allowable cost price list at least every seven business
days, and provide prompt notification of the pricing changes to network
pharmacies.
c. Disclose the sources utilized for setting maximum allowable cost price rates on
each maximum allowable cost price list included under the contract and identify
each maximum allowable cost price list that applies to the contracted pharmacy. A
pharmacy benefits manager shall make the list of the maximum allowable costs
available to a contracted pharmacy in a format that is readily accessible and
usable to the contracted pharmacy.
d. Ensure maximum allowable cost prices are not set below sources utilized by the
pharmacy benefits manager.
e. Provide a reasonable administrative appeals procedure to allow a dispensing
pharmacy provider to contest a listed maximum allowable price rate. The
pharmacy benefits manager shall provide a determination to a provider that has
contested a maximum allowable price rate within seven business days. If an
update to the maximum allowable price rate for an appealed drug is warranted,
the pharmacy benefits manager shall make the change based on the date of the
determination and make the adjustment effective for all similarly situated
pharmacy providers in this state within the network.
f. Ensure dispensing fees are not included in the calculation of maximum allowable
cost price reimbursement to pharmacy providers.
3. A pharmacy benefits manager may not place a prescription drug on a maximum
allowable price list unless:
a. The drug has at least two nationally available, therapeutically equivalent, multiple
source drugs or a generic drug is available only from one manufacturer;
b. The drug is listed as therapeutically equivalent and pharmaceutically equivalent
or "A" or "B" rated in the United States food and drug administration’s most recent
version of the "Orange Book" or the drug is "Z" rated; and
c. The drug is generally available for purchase by pharmacies in the state from
national or regional wholesalers and not obsolete.
4. This section does not apply to state Medicaid programs.
5. A pharmacy benefits manager that violates this section is guilty of a class B
misdemeanor.