Download as PDF
304.17A-162 Contract between pharmacy benefit manager and contracted
pharmacy -- Contents -- Resolution of disputes over maximum allowable
cost pricing -- Duties of pharmacy benefit manager.
(1)
(2)
All contracts between a 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 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.
The right to appeal shall be limited to sixty (60) days following the
initial claim;
2.
The appeal shall be investigated and resolved within ten (10) days;
and
3.
If the appeal is denied, the pharmacy benefit manager shall provide
the reason for the denial and 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
(c) Within one (1) year from June 25, 2013, a process to provide for
retroactive reimbursements.
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 drugs subject to maximum
allowable cost and the actual maximum allowable cost for each drug;
(c) Review and make necessary adjustments to the maximum allowable cost
for every drug at least every fourteen (14) days; and
(d) Make available to a contracted pharmacy weekly updates to the list of
drugs subject to maximum allowable cost and the actual maximum
allowable cost for each drug.
Effective:June 25, 2013
History: Created 2013 Ky. Acts ch. 109, sec. 2, effective June 25, 2013.
Disclaimer: These codes may not be the most recent version. Kentucky may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.