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Indiana Code Title 27. Insurance § 27-1-24.2-15

Current as of January 02, 2024 | Updated by Findlaw Staff

<Section effective January 1, 2026.>

Sec. 15. (a) A contract between a pharmacy or pharmacist and an insurer, a pharmacy benefit manager, or any other administrator of pharmacy benefits for the provision of pharmacy or pharmacist services under a health plan, either directly or through a pharmacy services administrative organization or group purchasing organization, must include provisions that do the following:

(1) Outline the terms and conditions for the provision of pharmacy or pharmacist services.

(2) Subject to subsection (b), prohibit the insurer, pharmacy benefit manager, or other administrator from retroactively denying, reducing reimbursement for, or seeking any refunds or recoupments for a claim for pharmacy or pharmacist services, in whole or in part, from the pharmacy or pharmacist after returning a paid claim response as part of the adjudication of the claim, including claims for the cost of a medication or dispensed product and claims for pharmacy or pharmacist services that are deemed ineligible for coverage, unless:

(A) the original claim was submitted fraudulently;  or

(B) the pharmacy or pharmacist received an actual overpayment.

(3) Prohibit the insurer, pharmacy benefit manager, or other administrator from reimbursing the pharmacy or pharmacist for a prescription drug or other service at a net amount that is less than the greater of the following:

(A) The amount the insurer, pharmacy benefit manager, or other administrator reimburses itself or a pharmacy affiliate for the same prescription drug by national drug code number or service.

(B) The following amount, as applicable:

(i) If the prescription drug or service is administered, dispensed, or provided at a pharmacy that is a licensed premises (as defined in IC 7.1-1-3-20), the actual acquisition cost for the prescription drug or service plus a fair and reasonable dispensing fee.

(ii) If the prescription drug or service is administered, dispensed, or provided at a pharmacy not described in item (i), the national average drug acquisition cost (NADAC) for the prescription drug or service, as determined by the federal Centers for Medicare and Medicaid Services at the time the prescription drug or service is administered, dispensed, or provided plus a professional dispensing fee equal to the Medicaid fee for service dispensing fee under 405 IAC 5-24-6.

(b) An insurer, a pharmacy benefit manager, or any other administrator of pharmacy benefits may not request a refund or make a recoupment of a dispensing fee paid to the pharmacy if the correct medication was dispensed to the patient.

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Cite this article: FindLaw.com - Indiana Code Title 27. Insurance § 27-1-24.2-15 - last updated January 02, 2024 | https://codes.findlaw.com/in/title-27-insurance/in-code-sect-27-1-24-2-15/

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