Okla. Stat. tit. 59, § 59-360v2

provider.

A. The pharmacy benefits manager shall, with respect to

contracts between a pharmacy benefits manager and a provider,

including a pharmacy service administrative organization:

l. Include in such contracts the specific sources utilized to

determine the maximum allowable cost (MAC) pricing of the pharmacy,

update MAC pricing at least every seven (7) calendar days, and

establish a process for providers to readily access the MAC list

specific to that provider;

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2. In order to place a drug on the MAC list, ensure that the

drug is listed as “A” or “B” rated in the most recent version of the

FDA’s Approved Drug Products with Therapeutic Equivalence

Evaluations, also known as the Orange Book, and the drug is

generally available for purchase by pharmacies in the state from

national or regional wholesalers and is not obsolete;

3. Ensure dispensing fees are not included in the calculation

of MAC price reimbursement to pharmacy providers;

4. Provide a reasonable administration appeals procedure to

allow a provider, a provider’s representative and a pharmacy service

administrative organization to contest reimbursement amounts within

fourteen (14) calendar days of the final adjusted payment date. The

pharmacy benefits manager shall not prevent the pharmacy or the

pharmacy service administrative organization from filing

reimbursement appeals in an electronic batch format. The pharmacy

benefits manager must respond to a provider, a provider’s

representative and a pharmacy service administrative organization

who have contested a reimbursement amount through this procedure

within ten (10) calendar days. The pharmacy benefits manager must

respond in an electronic batch format to reimbursement appeals filed

in an electronic batch format. The pharmacy benefits manager shall

not require a pharmacy or pharmacy services administrative

organization to log into a system to upload individual claim appeals

or to download individual appeal responses. If a price update is

warranted, the pharmacy benefits manager shall make the change in

the reimbursement amount, permit the dispensing pharmacy to reverse

and rebill the claim in question, and make the reimbursement amount

change retroactive and effective for all contracted providers; and

5. If a below-cost reimbursement appeal is denied, the PBM

shall provide the reason for the denial, including the National Drug

Code (NDC) number from, and the name of, the specific national or

regional wholesalers doing business in this state where the drug is

currently in stock and available for purchase by the dispensing

pharmacy at a price below the PBM’s reimbursement price. If the NDC

number provided by the pharmacy benefits manager is not available

below the acquisition cost obtained from the pharmaceutical

wholesaler from whom the dispensing pharmacy purchases the majority

of the prescription drugs that are dispensed, the pharmacy benefits

manager shall immediately adjust the reimbursement amount, permit

the dispensing pharmacy to reverse and rebill the claim in question,

and make the reimbursement amount adjustment retroactive and in

effect for all contracted providers for future claims billed.

B. The reimbursement appeal requirements in this section shall

apply to all drugs, medical products, or devices reimbursed

according to any payment methodology, including, but not limited to:

1. Average acquisition cost, including the National Average

Drug Acquisition Cost;

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2. Average manufacturer price;

3. Average wholesale price;

4. Brand effective rate or generic effective rate;

5. Discount indexing;

6. Federal upper limits;

7. Wholesale acquisition cost; and

8. Any other term that a pharmacy benefits manager or an

insurer of a health benefit plan may use to establish reimbursement
n Cost;

Oklahoma Statutes - Title 59. Professions and Occupations Page 349

2. Average manufacturer price;

3. Average wholesale price;

4. Brand effective rate or generic effective rate;

5. Discount indexing;

6. Federal upper limits;

7. Wholesale acquisition cost; and

8. Any other term that a pharmacy benefits manager or an

insurer of a health benefit plan may use to establish reimbursement

rates to a pharmacist or pharmacy for pharmacist services.

C. The pharmacy benefits manager shall not place a drug on a

MAC list, unless there are at least two therapeutically equivalent,

multiple-source drugs, generally available for purchase by

dispensing retail pharmacies from national or regional wholesalers.

D. In the event that a drug is placed on the FDA Drug Shortages

Database, pharmacy benefits managers shall reimburse claims to

pharmacies at no less than the wholesale acquisition cost for the

specific NDC number being dispensed.

E. The pharmacy benefits manager shall not require

accreditation or licensing of providers, or any entity licensed or

regulated by the State Board of Pharmacy, other than by the State

Board of Pharmacy or federal government entity as a condition for

participation as a network provider.

F. A pharmacy or pharmacist may decline to provide the

pharmacist clinical or dispensing services to a patient or pharmacy

benefits manager if the pharmacy or pharmacist is to be paid less

than the pharmacy’s cost for providing the pharmacist clinical or

dispensing services.

G. The pharmacy benefits manager shall provide a dedicated

telephone number, email address and names of the personnel with

decision-making authority regarding MAC appeals and pricing.

H. Any pharmacy benefits manager (PBM) that leases, rents, or

otherwise makes its provider network or contracts available to

another pharmacy benefits manager shall:

1. Provide notice to all contracted providers of the lease

arrangement and the responsibilities of each party involved; and

2. Provide contact information in each paid or rejected claim

response that notifies the provider which contract the claim is

adjudicating against, who is processing the claim, and a phone

number to address provider issues; and

3. Transmit the network reimbursement identification

information with each claim response in NCPDP field 545-2F.

I. Any pharmacy benefits manager (PBM) that leases, rents, or

otherwise makes its provider network or contracts available to

another pharmacy benefits manager shall not combine any Employee

Retirement Income Security Act (ERISA) or government plans with any

non-ERISA or nongovernment plans.

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J. 1. Effective rate contracting is hereby prohibited in all

agreements between pharmacies or contracting agents acting on behalf

of a pharmacy and a PBM or third-party payors. No PBM or third-

party payor shall enter into any contract that establishes payment

for services or medications based on an effective rate of

reimbursement.

2. Any PBM or third-party payor found to be in violation of

this section shall be subject to penalties, including, but not

limited to, fines, revocation of licensure, or other disciplinary

actions.

K. The provisions of this section shall not be waived, voided,

or nullified by contract.