Utah Code 31A-46-303. Insurer and pharmacy benefit management services — Registration — Maximum allowable cost — Audit restrictions
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(1) An insurer and an insurer’s pharmacy benefit manager is subject to the pharmacy audit provisions of Section 58-17b-622.
Terms Used In Utah Code 31A-46-303
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Contract: A legal written agreement that becomes binding when signed.
- Drug: means the same as that term is defined in Section 58-17b-102. See Utah Code 31A-46-102
- Insurer: means the same as that term is defined in Section 31A-22-636. See Utah Code 31A-46-102
- Maximum allowable cost: means :(13)(a) a maximum reimbursement amount for a group of pharmaceutically and therapeutically equivalent drugs; or(13)(b) any similar reimbursement amount that is used by a pharmacy benefit manager to reimburse pharmacies for multiple source drugs. See Utah Code 31A-46-102
- Medicaid program: means the same as that term is defined in Section 26B-3-101. See Utah Code 31A-46-102
- Obsolete: means a product that may be listed in national drug pricing compendia but is no longer available to be dispensed based on the expiration date of the last lot manufactured. See Utah Code 31A-46-102
- Pharmacy: means the same as that term is defined in Section 58-17b-102. See Utah Code 31A-46-102
- Pharmacy benefit manager: means a person licensed under this chapter to provide a pharmacy benefits management service. See Utah Code 31A-46-102
- Process: means a writ or summons issued in the course of a judicial proceeding. See Utah Code 68-3-12.5
- State: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
- United States: includes each state, district, and territory of the United States of America. See Utah Code 68-3-12.5
(2) A pharmacy benefit manager shall not use maximum allowable cost as a basis for reimbursement to a pharmacy unless:(2)(a) the drug is listed as “A” or “B” rated in the most recent version of the United States Food and Drug Administration’s approved drug products with therapeutic equivalent evaluations, also known as the “Orange Book,” or has an “NR” or “NA” rating or similar rating by a nationally recognized reference; and(2)(b) the drug is:(2)(b)(i) generally available for purchase in this state from a national or regional wholesaler; and(2)(b)(ii) not obsolete.(3) The maximum allowable cost may be determined using comparable and current data on drug prices obtained from multiple nationally recognized, comprehensive data sources, including wholesalers, drug file vendors, and pharmaceutical manufacturers for drugs that are available for purchase by pharmacies in the state.(4) For every drug for which the pharmacy benefit manager uses maximum allowable cost to reimburse a contracted pharmacy, the pharmacy benefit manager shall:(4)(a) include in the contract with the pharmacy information identifying the national drug pricing compendia and other data sources used to obtain the drug price data;(4)(b) review and make necessary adjustments to the maximum allowable cost, using the most recent data sources identified in Subsection (4)(a), at least once per week;(4)(c) provide a process for the contracted pharmacy to appeal the maximum allowable cost in accordance with Subsection (5); and(4)(d) include in each contract with a contracted pharmacy a process to obtain an update to the pharmacy product pricing files used to reimburse the pharmacy in a format that is readily available and accessible.(5)(5)(a) The right to appeal in Subsection (4)(c) shall be:(5)(a)(i) limited to 21 days following the initial claim adjudication; and(5)(a)(ii) investigated and resolved by the pharmacy benefit manager within 14 business days.(5)(b) If an appeal is denied, the pharmacy benefit manager shall provide the contracted pharmacy with the reason for the denial and the identification of the national drug code of the drug that may be purchased by the pharmacy at a price at or below the price determined by the pharmacy benefit manager.(6) The contract with each pharmacy shall contain a dispute resolution mechanism in the event either party breaches the terms or conditions of the contract.(7) This section does not apply to a pharmacy benefit manager when the pharmacy benefit manager is providing pharmacy benefit management services on behalf of the Medicaid program.