402-N:3 Provider Contract Standards for Pharmacy Benefit Managers. –
I. All contracts between a carrier or pharmacy benefit manager and a contracted pharmacy shall include:
(a) The sources used by the pharmacy benefit manager to calculate the drug product reimbursement paid for covered drugs available under the pharmacy health benefit plan administered by the carrier or pharmacy benefit manager.
(b) A process to appeal, investigate, and resolve disputes regarding the maximum allowable cost pricing. The process shall include the following provisions:
(1) A provision granting the contracted pharmacy or pharmacist at least 30 business days following the initial claim to file an appeal;
(2) A provision requiring the carrier or pharmacy benefit manager to investigate and resolve the appeal within 30 business days;
(3) A provision requiring that, if the appeal is denied, the carrier or pharmacy benefit manager shall:
(A) Provide the reason for the denial; and
(B) Identify the national drug code of a drug product that may be purchased by contracted pharmacies at a price at or below the maximum allowable cost; and
(4) A provision requiring that, if an appeal is granted, the carrier or pharmacy benefits manager shall within 30 business days after granting the appeal:
(A) Make the change in the maximum allowable cost; and
(B) Permit the challenging pharmacy or pharmacist to reverse and rebill the claim in question.
II. For every drug for which the pharmacy benefit manager establishes a maximum allowable cost to determine the drug product reimbursement, the pharmacy benefit manager shall:
(a) Include in the contract with the pharmacy information identifying the national drug pricing compendia or sources used to obtain the drug price data.
(b) Make available to a contracted pharmacy the actual maximum allowable cost for each drug.
(c) Review and make necessary adjustments to the maximum allowable cost for every drug for which the price has changed at least every 14 days.
III. [Repealed.]