2017 Louisiana Laws
Revised Statutes
TITLE 22 - Insurance
RS 22:1865 - Appeals
§1865. Appeals
A. The pharmacy benefits manager shall provide a reasonable administrative appeal procedure to allow pharmacies to challenge maximum allowable costs for a specific NDC or NDCs as not meeting the requirements of this Subpart or being below the cost at which the pharmacy may obtain the NDC. Within seven business days after the applicable fill date, a pharmacy may file an appeal by following the appeal process as provided for in this Subpart. The pharmacy benefits manager shall respond to a challenge within seven business days after receipt of the challenge.
B. If an appeal made pursuant to this Section is upheld, the pharmacy benefits manager shall take the following actions:
(1) Make the change in the Maximum Allowable Cost List.
(2) Permit the challenging pharmacy or pharmacist to reverse and rebill the claim in question.
(3) Make the change effective for each similarly situated pharmacy as defined by the payor subject to the Maximum Allowable Cost List.
C. If an appeal made pursuant to this Section is denied, the pharmacy benefits manager shall provide the challenging pharmacy or pharmacist the NDC number from national or regional wholesalers operating in Louisiana.
D. A violation of this Subpart shall be deemed an unfair or deceptive act and practice pursuant to R.S. 22:1961 et seq.
Acts 2014, No. 391, §1.
