2019 South Carolina Code of Laws
Title 38 - Insurance
Chapter 71 - Accident And Health Insurance
Section 38-71-2140. Process for appeals.
Section effective until January 1, 2021.
(A) A pharmacy benefit manager must establish a process by which a contracted pharmacy can appeal the provider's reimbursement for a drug subject to maximum allowable cost pricing. A contracted pharmacy has ten calendar days after the applicable fill date to appeal a maximum allowable cost if the reimbursement for the drug is less than the net amount that the network provider paid to the supplier of the drug. A pharmacy benefit manager must respond to a challenge within ten calendar days of the contracted pharmacy making the claim for which appeal has been submitted.
(B) At the beginning of the term of the network provider's contract, and upon renewal, a pharmacy benefit manager must provide to network providers a telephone number at which a network provider can contact the pharmacy benefit manager to process an appeal.
(C) If an appeal is denied, the pharmacy benefit manager must provide the reason for the denial and the name and the national drug code number from national or regional wholesalers operating in South Carolina.
(D) If an appeal is sustained, the pharmacy benefit manager must make an adjustment in the drug price effective the date the challenge is resolved and make the adjustment applicable to all similarly situated network pharmacy providers, as determined by the managed care organization or pharmacy benefit manager, as appropriate."
HISTORY: 2016 Act No. 163 (S.849), Section 1, eff January 1, 2016.
Repeal
2019 Act No. 48, Section 4, provides that Article 20 of Chapter 71, Title 38 is repealed, effective January 1, 2021.
Editor's Note
2016 Act No. 163, Section 2, provides as follows:
"SECTION 2. This article applies to contracts between pharmacies and pharmacy benefit managers that are entered into, renewed, or extended on or after the effective date of this act."
2019 Act No. 48, Section 4, provides as follows:
"SECTION 4. Article 20 of Chapter 71, Title 38 is repealed."
