Pharmacy benefit managers – contracting pharmacies: When a pharmacy benefit manager reimburses a contracting pharmacy contracting for a drug, on a maximum allowable cost basis:
1) A pharmacy benefit manager is required to include in any contract initially entered into or renewed, on or after January 15, 2016, with a contracting pharmacy information that identifies national drug price compendia or maximum allowable cost data sources; and
2) A pharmacy benefit manager is required to make available to the contracting pharmacy, upon request, up-to-date maximum allowable cost list(s) relevant to the pharmacy’s patients in a Web-based or comparable format.
A drug may not included on a list of, or reimbursed at, maximum allowable cost unless (1) it is rated “A” or “B” in the FDA’s Orange Book or as “NA,” “NR,” or “Z” in a nationally recognized price reference; (2) the drug is generally available for purchase in the state from a national or regional wholesaler; and (3) the drug is not obsolete.
Pharmacy benefit managers must have an appeals process. The code provides contracting pharmacies with appealable causes of action.