N.J. Admin. Code § 11:4-62.4

Current through Register Vol. 56, No. 21, November 4, 2024

Section 11:4-62.4 - Appeals

(a) All contracts between a pharmacy benefits manager and a contracted pharmacy shall include a process to appeal, investigate, and resolve disputes regarding multiple source generic drug pricing. The contract provision establishing the process shall include the following:

1. The right to appeal shall be limited to 14 calendar days following the initial claim;

2. The appeal shall be investigated and resolved by the pharmacy benefits manager through an internal process within 14 calendar days of receipt of the appeal by the pharmacy benefits manager; and

3. A telephone number at which a pharmacy may contact the pharmacy benefits manager and speak with an individual who is involved in the appeals process.

(b) In addition to (a) above, the contract shall also provide that:

1. If the appeal is denied, the pharmacy benefits manager shall provide the reason for the denial and identify the national drug code of a drug product that is available for purchase by contracted pharmacies in this State from wholesalers registered pursuant to N.J.S.A. 24:6B-1 et seq., at a price which is equal to or less than the maximum allowable cost for the appealed drug as determined by the pharmacy benefits manager; and

2. If the appeal is approved, the pharmacy benefits manager shall make the price correction, permit the reporting pharmacy to reverse and rebill the appealed claim, and make the price correction effective for all similarly situated pharmacies from the date of the approved appeal.

N.J. Admin. Code § 11:4-62.4

Adopted by 50 N.J.R. 198(b), effective 1/2/2018