§ 360. Pharmacy benefits manager--Contractual duties to provider
Oklahoma Statutes AnnotatedTitle 59. Professions and OccupationsEffective: May 4, 2021
Effective: May 4, 2021
59 Okl.St.Ann. § 360
§ 360. Pharmacy benefits manager--Contractual duties to provider
2. In order to place a drug on the MAC list, ensure that the drug is listed as “A” or “B” rated in the most recent version of the FDA's Approved Drug Products with Therapeutic Equivalence Evaluations, also known as the Orange Book, and the drug is generally available for purchase by pharmacies in the state from national or regional wholesalers and is not obsolete;
4. Provide a reasonable administration appeals procedure to allow a provider, a provider's representative and a pharmacy service administrative organization to contest reimbursement amounts within fourteen (14) business days of the final adjusted payment date. The pharmacy benefits manager shall not prevent the pharmacy or the pharmacy service administrative organization from filing reimbursement appeals in an electronic batch format. The pharmacy benefits manager must respond to a provider, a provider's representative and a pharmacy service administrative organization who have contested a reimbursement amount through this procedure within ten (10) business days. The pharmacy benefits manager must respond in an electronic batch format to reimbursement appeals filed in an electronic batch format. The pharmacy benefits manager shall not require a pharmacy or pharmacy services administrative organization to log into a system to upload individual claim appeals or to download individual appeal responses. If a price update is warranted, the pharmacy benefits manager shall make the change in the reimbursement amount, permit the dispensing pharmacy to reverse and rebill the claim in question, and make the reimbursement amount change retroactive and effective for all contracted providers; and
5. If a below-cost reimbursement appeal is denied, the PBM shall provide the reason for the denial, including the National Drug Code number from the specific national or regional wholesalers where the drug is available for purchase by the dispensing pharmacy at a price below the PBM's reimbursement price. If the pharmacy benefits manager cannot provide a specific national or regional wholesaler where the drug can be purchased by the dispensing pharmacy at a price below the pharmacy benefits manager's reimbursement price, the pharmacy benefits manager shall immediately adjust the reimbursement amount, permit the dispensing pharmacy to reverse and rebill the claim in question, and make the reimbursement amount adjustment retroactive and effective for all contracted providers.
Credits
Laws 2014, c. 263, § 4, eff. July 1, 2014; Laws 2016, c. 285, § 8, eff. Nov. 1, 2016; Laws 2021, c. 409, § 5, emerg. eff. May 4, 2021.
59 Okl. St. Ann. § 360, OK ST T. 59 § 360
Current with emergency effective legislation through Chapter 295 of the Second Regular Session of the 59th Legislature (2024). Some sections may be more current, see credits for details.
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