Delaware Code Title 18 Sec. 3324A – Appeals
(a) A pharmacy benefits manager must establish a process by which a contracted pharmacy can appeal the provider’s reimbursement for a drug subject to maximum allowable cost pricing. A contracted pharmacy has 10 calendar days after the applicable fill date to appeal a maximum allowable cost if the reimbursement for the drug is less than the net amount that the network provider paid to the supplier of the drug. A pharmacy benefits manager must respond with notice that the appeal has been denied or granted within 10 calendar days of the contracted pharmacy making the claim for which an appeal has been submitted.
Terms Used In Delaware Code Title 18 Sec. 3324A
- 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.
- Claim: means a request from a pharmacy or pharmacist to be reimbursed for the cost of filling or refilling a prescription for a drug or for providing a medical supply or device. See Delaware Code Title 18 Sec. 3321A
- Contract: A legal written agreement that becomes binding when signed.
- Contracted pharmacy: means a pharmacy that participates in the network of a pharmacy benefits manager through a contract with a pharmacy benefits manager, a pharmacy services administration organization, or a group purchasing organization. See Delaware Code Title 18 Sec. 3321A
- Freedom of Information Act: A federal law that mandates that all the records created and kept by federal agencies in the executive branch of government must be open for public inspection and copying. The only exceptions are those records that fall into one of nine exempted categories listed in the statute. Source: OCC
- Maximum allowable cost: means the maximum amount that a pharmacy benefits manager will reimburse a pharmacist or pharmacy for the cost of a multi-sourced drug, medical product, or device. See Delaware Code Title 18 Sec. 3321A
- Network providers: means those pharmacists and pharmacies who provide covered health-care services or supplies to an insured or a member pursuant to a contract with an insurer or pharmacy benefits manager. See Delaware Code Title 18 Sec. 3321A
- Pharmacist: means as defined under § 2502 of Title 24. See Delaware Code Title 18 Sec. 3321A
- Pharmacy: means as defined under § 2502 of Title 24. See Delaware Code Title 18 Sec. 3321A
- Pharmacy benefits management services: means as defined under § 3351A of this title. See Delaware Code Title 18 Sec. 3321A
- Pharmacy benefits manager: means as defined under § 3302A of this title. See Delaware Code Title 18 Sec. 3321A
- State: means the State of Delaware; and when applied to different parts of the United States, it includes the District of Columbia and the several territories and possessions of the United States. See Delaware Code Title 1 Sec. 302
- Subpoena: A command to a witness to appear and give testimony.
(b) At the beginning of the term of a network provider’s contract, and upon renewal, a pharmacy benefits manager must provide to network providers a telephone number and e-mail address at which a network provider can contact the pharmacy benefits manager to process an appeal under this section.
(c) If an appeal is denied, the pharmacy benefits manager must provide the reason for the denial and the name and national drug code number of the national or regional wholesalers operating in this State that have the drug in stock at a price below the maximum allowable cost.
(d) If the appeal is granted the pharmacy benefits manger shall do the following:
(1) a. Adjust the maximum allowable cost for the drug as of the date of the original claim for payment.
b. Without requiring the appealing pharmacy to reverse and rebill the claims, provide reimbursement for the claim and any subsequent and similar claims under similarly applicable contracts with the pharmacy benefits manager as follows:
1. For the original claim, in the first remittance to the pharmacy after the date the appeal was granted.
2. For subsequent and similar claims under similarly applicable contracts, in the second remittance to the pharmacy after the date the appeal was granted.
(2) For a similarly situated contracted pharmacy in this State, do all of the following:
a. Adjust the maximum allowable cost for the drug as of the date the appeal was granted.
b. Provide notice to the pharmacy or the pharmacy’s contracted agent of all of the following:
1. That an appeal was granted.
2. That without filing a separate appeal, the pharmacy or the pharmacy’s contracted agent may reverse and rebill a similar claim.
(e) A pharmacy benefits manager shall make available on its website information about the appeal process, including all of the following:
(1) A telephone number at which the contracted pharmacy may contact the department or office responsible for processing appeals for the pharmacy benefits manager to speak to an individual specifically or leave a message for an individual or office who is responsible for processing appeals.
(2) An email address of the department or office responsible for processing appeals to which an individual who responsible for processing appeals has access.
(f) A pharmacy benefits manager may not charge a contracted pharmacy a fee related to the re-adjudication of a claim resulting from a granted appeal under subsection (d) of this section or the granting of an appeal under subsection (h) of this section.
(g) A pharmacy benefits manager may not retaliate against a contracted pharmacy for exercising its right to appeal to the pharmacy benefits manager under subsection (a) of this section or to the Commissioner under subsection (h) of this section.
(h) (1) If a pharmacy benefits manager denies an appeal and a contracted pharmacy files an appeal with the Commissioner, the Commissioner shall do all of the following:
a. Review the pharmacy benefits manager’s compensation program to ensure that the reimbursement for pharmacy benefits management services paid to the pharmacist or a pharmacy complies with this subchapter and the terms of the contract.
b. Based on a determination made by the Commissioner under paragraph (h)(1)a. of this section, do 1 of the following:
1. Deny the appeal.
2. Grant the appeal and order the pharmacy benefits manager to pay the claim in accordance with the Commissioner’s findings.
(2) All pricing information and data collected by the Commissioner during a review required by paragraph (h)(1) of this section is confidential and not subject to subpoena or the Freedom of Information Act, Chapter 100 of Title 29.
80 Del. Laws, c. 245, § 1; 82 Del. Laws, c. 115, § 3; 83 Del. Laws, c. 256, § 4;