Utah Code § 31A-46-303 — Utah Code / Title 31A / Chapter 31A-46 / § 31A-46-303
§ 31A-46-303. Insurer and pharmacy benefit management services -- Registration -- Maximum allowable cost -- Audit restrictions.
Status: in_force

(1) An insurer and an insurer's pharmacy benefit manager is subject to the pharmacy audit provisions of Section 58-17b-622. (2) A pharmacy benefit manager shall not use maximum allowable cost as a basis for reimbursement to a pharmacy unless: (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 (b) the drug is: (i) generally available for purchase in this state from a national or regional wholesaler; and (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: (a) make a list available to a network pharmacy upon request in a format that: (i) is electronic; (ii) is computer accessible and searchable; (iii) identifies all drugs for which maximum allowable costs have been established; and (iv) for each drug specifies: (A) the national drug code; and (B) the maximum allowable cost; (b) 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; (c) review and make necessary adjustments to the maximum allowable cost, using the most recent data sources identified in Subsection (4)(b), at least once per week; (d) provide a process for the contracted pharmacy to appeal the maximum allowable cost in accordance with Subsection (5); and (e) 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) (a) The right to appeal in Subsection (4)(d) shall be: (i) limited to 21 days following the initial claim adjudication; and (ii) investigated and resolved by the pharmacy benefit manager within 14 business days. (b) A pharmacy benefit manager shall: (i) provide as part of the appeals process: (A) a dedicated telephone number, electronic mail address, and website for the purpose of submitting appeals; and (B) the ability for a pharmacy to submit an appeal directly to the pharmacy benefit manager or through the pharmacy's pharmacy services administrative organization; and (ii) allow a pharmacy to submit documentation in support of the pharmacy's appeal on paper or electronically. (c) If an appeal is denied, the pharmacy benefit manager shall provide the contracted pharmacy: (i) the reason for the denial; (ii) 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; and (iii) the specific basis upon which the pharmacy benefit manager can show that the drug is available for purchase at or below the maximum allowable cost. (d) If an appeal is upheld or the pharmacy benefit manager cannot show the drug is available for purchase at or below the maximum allowable cost for a similarly situated pharmacy as the pharmacy that submitted the appeal, the pharmacy benefit manager shall: (i) make an adjustment for the pharmacy that appealed; (ii) permit the dispensing pharmacy to reverse the claim and resubmit an adjusted claim without an additional charge; and (iii) consider additional action consistent with the outcome of the appeal. (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.