760 IAC 5-4-2 - Disputes

Authority: IC 27-1-24.5-20

Affected: IC 27-1-24.5-22

Sec. 2.

A pharmacy benefit manager shall establish a process for contracted pharmacies, pharmacy services administrative organizations, and group purchasing organizations to appeal, investigate, and resolve disputes regarding maximum allowable cost pricing that includes the following:

(1) The right to appeal a claim in accordance with IC 27-1-24.5-22(b)(1).

(2) A requirement that the appeal be investigated and resolved within thirty (30) calendar days after the appeal is received.

(3) A requirement that if an appeal is denied, the pharmacy benefit manager must do the following:

(A) Provide a reason for the appeal denial.

(B) Provide the appealing contracted pharmacy, pharmacy services administrative organization, or group purchasing organization with the national drug code of a prescription drug that is generally available for purchase by pharmacies in Indiana:

(i) from a national or regional wholesaler licensed and operating in Indiana; and

(ii) for a price at or below the maximum allowable cost price as determined by the pharmacy benefit manager.

(4) A requirement that if an appeal is approved, the pharmacy benefit manager must follow the procedures set forth in IC 27-1-24.5-22(b)(4).

Notes

760 IAC 5-4-2

Department of Insurance; 760 IAC 5-4-1; filed 2/23/2023, 9:48 a.m.: 20230322-IR-760220287FRA