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Pennsylvania Statutes Title 40 P.S. Insurance § 4533. Multiple source drug pricing appeals process

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(a) Process to be established.--All contracts between a PBM or a pharmacy or, alternatively, a pharmacy's contracting agent, such a PSAO, shall include a process to appeal, investigate and resolve disputes regarding multiple source 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 PBM through an internal process within 14 calendar days of receipt of the appeal by the PBM.

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

(b) Denial.--If a PBM denies an appeal, the PBM shall provide the reason for the denial and identify the national drug code of an equivalent drug that is available for purchase by network retail pharmacies in this Commonwealth from wholesalers at a price that is equal to or less than the maximum allowable cost for the appealed drug as determined by the PBM.

(c) Approval.--If a PBM grants an appeal, the PBM 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.

Cite this article: - Pennsylvania Statutes Title 40 P.S. Insurance § 4533. Multiple source drug pricing appeals process - last updated January 01, 2019 |

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