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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.
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