§ 31A-46-304 — Claims practices.

(1) A pharmacy benefit manager shall permit a pharmacy to collect the amount of a customer's cost share from any source.
(2) A pharmacy benefit manager may not deny or reduce a reimbursement to a pharmacy or a pharmacist after the adjudication of the claim, unless:

(2)(a) the pharmacy or pharmacist submitted the original claim fraudulently;
(2)(b) the original reimbursement was incorrect because:
(2)(b)(i) the pharmacy or pharmacist had already been paid for the pharmacy service; or
(2)(b)(ii) an unintentional error resulted in an incorrect reimbursement; or
(2)(c) the pharmacy service was not rendered by the pharmacy or pharmacist.
(3) Subsection (2) does not apply if:

(3)(a) any form of an investigation or audit of pharmacy records for fraud, waste, abuse, or other intentional misrepresentation indicates that the pharmacy or pharmacist engaged in criminal wrongdoing, fraud, or other intentional misrepresentation; or
(3)(b) the reimbursement is reduced as the result of the reconciliation of a reimbursement amount under a performance contract if:
(3)(b)(i) the performance contract lays out clear performance standards under which the reimbursement for a specific drug may be increased or decreased; and
(3)(b)(ii) the agreement between the pharmacy benefit manager and the pharmacy or pharmacist explicitly states, in a separate document that is signed by the pharmacy benefit manager and the pharmacy or pharmacist, that the provisions of Subsection (2) do not apply.

Legislative History

Amended by Chapter 198, 2020 General Session