Section 760 IAC 5-4-2 - DisputesAuthority: IC 27-1-24.5-20
Affected: IC 27-1-24.5-22
Sec. 2.
A pharmacy benefit manager shall establish a process for contracted pharmacies, pharmacy services administrative organizations, and group purchasing organizations to appeal, investigate, and resolve disputes regarding maximum allowable cost pricing that includes the following:
(1) The right to appeal a claim in accordance with IC 27-1-24.5-22(b)(1).(2) A requirement that the appeal be investigated and resolved within thirty (30) calendar days after the appeal is received.(3) A requirement that if an appeal is denied, the pharmacy benefit manager must do the following: (A) Provide a reason for the appeal denial.(B) Provide the appealing contracted pharmacy, pharmacy services administrative organization, or group purchasing organization with the national drug code of a prescription drug that is generally available for purchase by pharmacies in Indiana: (i) from a national or regional wholesaler licensed and operating in Indiana; and(ii) for a price at or below the maximum allowable cost price as determined by the pharmacy benefit manager.(4) A requirement that if an appeal is approved, the pharmacy benefit manager must follow the procedures set forth in IC 27-1-24.5-22(b)(4).Department of Insurance; 760 IAC 5-4-1; filed 2/23/2023, 9:48 a.m.: 20230322-IR-760220287FRA