2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.388 - Maximum allowable costs — definitions — contract requirements — reimbursement — appeals process required.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 2016
*376.388. Maximum allowable costs — definitions — contract requirements — reimbursement — appeals process required. —
1. As used in this section, unless the context requires otherwise, the following terms shall mean:
(1)
"Contracted pharmacy"
or
"pharmacy"
, a pharmacy located in Missouri participating in the network of a pharmacy benefits manager through a direct or indirect contract;
(2)
"Health carrier"
, an entity subject to the insurance laws and regulations of this state that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, a nonprofit hospital and health service corporation, or any other entity providing a plan of health insurance, health benefits, or health services, except that such plan shall not include any coverage pursuant to a liability insurance policy, workers' compensation insurance policy, or medical payments insurance issued as a supplement to a liability policy;
(3)
"Maximum allowable cost"
, the per-unit amount that a pharmacy benefits manager reimburses a pharmacist for a prescription drug, excluding a dispensing or professional fee;
(4)
"Maximum allowable cost list"
or
"MAC list"
, a listing of drug products that meet the standard described in this section;
(5)
"Pharmacy"
, as such term is defined in chapter 338;
(6)
"Pharmacy benefits manager"
, an entity that contracts with pharmacies on behalf of health carriers or any health plan sponsored by the state or a political subdivision of the state.
2. Upon each contract execution or renewal between a pharmacy benefits manager and a pharmacy or between a pharmacy benefits manager and a pharmacy's contracting representative or agent, such as a pharmacy services administrative organization, a pharmacy benefits manager shall, with respect to such contract or renewal:
(1) Include in such contract or renewal the sources utilized to determine maximum allowable cost and update such pricing information at least every seven days; and
(2) Maintain a procedure to eliminate products from the maximum allowable cost list of drugs subject to such pricing or modify maximum allowable cost pricing at least every seven days, if such drugs do not meet the standards and requirements of this section, in order to remain consistent with pricing changes in the marketplace.
3. A pharmacy benefits manager shall reimburse pharmacies for drugs subject to maximum allowable cost pricing that has been updated to reflect market pricing at least every seven days as set forth under subdivision (1) of subsection 2 of this section.
4. A pharmacy benefits manager shall not place a drug on a maximum allowable cost list unless there are at least two therapeutically equivalent multisource generic drugs, or at least one generic drug available from at least one manufacturer, generally available for purchase by network pharmacies from national or regional wholesalers.
5. All contracts between a pharmacy benefits manager and a contracted pharmacy or between a pharmacy benefits manager and a pharmacy's contracting representative or agent, such as a pharmacy services administrative organization, shall include a process to internally appeal, investigate, and resolve disputes regarding maximum allowable cost pricing. The process shall include the following:
(1) The right to appeal shall be limited to fourteen calendar days following the reimbursement of the initial claim; and
(2) A requirement that the pharmacy benefits manager shall respond to an appeal described in this subsection no later than fourteen calendar days after the date the appeal was received by such pharmacy benefits manager.
6. For appeals that are denied, the pharmacy benefits manager shall provide the reason for the denial and identify the national drug code of a drug product that may be purchased by contracted pharmacies at a price at or below the maximum allowable cost and, when applicable, may be substituted lawfully.
7. If the appeal is successful, the pharmacy benefits manager shall:
(1) Adjust the maximum allowable cost price that is the subject of the appeal effective on the day after the date the appeal is decided;
(2) Apply the adjusted maximum allowable cost price to all similarly situated pharmacies as determined by the pharmacy benefits manager; and
(3) Allow the pharmacy that succeeded in the appeal to reverse and rebill the pharmacy benefits claim giving rise to the appeal.
8. Appeals shall be upheld if:
(1) The pharmacy being reimbursed for the drug subject to the maximum allowable cost pricing in question was not reimbursed as required under subsection 3 of this section; or
(2) The drug subject to the maximum allowable cost pricing in question does not meet the requirements set forth under subsection 4 of this section.
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(L. 2016 S.B. 608 merged with S.B. 635 merged with S.B. 865 & 866)
Effective 8-28-16 (S.B. 635); 8-28-16 (S.B. 865 & 866); *10-14-16 (S.B. 608), see § 21.250
*S.B. 608 was vetoed July 5, 2016. The veto was overridden on September 14, 2016.