2020 Oklahoma Statutes
Title 59. Professions and Occupations
§59-360. Pharmacy benefits manager – Contractual duties to provider
A. The pharmacy benefits manager shall, with respect to contracts between a pharmacy benefits manager and a provider:
l. Include in such contracts the sources utilized to determine the maximum allowable cost (MAC) pricing of the pharmacy, update MAC pricing at least every seven (7) calendar days, and establish a process for providers to readily access the MAC list specific to that provider;
2. In order to place a drug on the MAC list, ensure that the drug is listed as "A" or "B" rated in the most recent version of the FDA's Approved Drug Products with Therapeutic Equivalence Evaluations, also known as the Orange Book, or has an "NR" or "NA" rating or a similar rating by a nationally recognized reference, and the drug is generally available for purchase by pharmacies in the state from national or regional wholesalers and is not obsolete;
3. Ensure dispensing fees are not included in the calculation of MAC price reimbursement to pharmacy providers;
4. Provide a reasonable administration appeals procedure to allow a provider or a provider's representative to contest reimbursement amounts within ten (10) business days of the final adjusted payment date. The pharmacy benefits manager must respond to a provider or provider’s representative who has contested a reimbursement amount through this procedure within ten (10) business days. If a price update is warranted, the pharmacy benefits manager shall make the change in the reimbursement amount, permit the challenging pharmacy to reverse and rebill the claim in question, and make the reimbursement amount change effective for each similarly contracted Oklahoma provider; and
5. If the reimbursement appeal is denied, the PBM shall provide the reason for the denial, including the National Drug Code number from national or regional wholesalers where the drug is generally available for purchase by pharmacies in the state at or below the PBM's reimbursement.
B. The pharmacy benefits manager may not place a drug on a MAC list, unless there are at least two therapeutically equivalent, multiple-source drugs, or at least one generic drug available from only one manufacturer, generally available for purchase by network pharmacies from national or regional wholesalers.
C. The pharmacy benefits manager shall not require accreditation or licensing of providers other than by the State Board of Pharmacy or other state or federal government entity.
Added by Laws 2014, c. 263, § 4, eff. July 1, 2014. Amended by Laws 2016, c. 285, § 8, eff. Nov. 1, 2016.
