760 IAC 5-4-2 Disputes

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).