Mississippi Code 1972 (2023) › Title 73 - PROFESSIONS AND VOCATIONS (§§ 73-1-1 — 73-79-1) › Chapter 21 - PHARMACISTS (§§ 73-21-1 — 73-21-205) › PHARMACY BENEFIT PROMPT PAY ACT (§§ 73-21-151 — 73-21-163) › Section 73-21-156 - Placement of drug on maximum allowable cost list; access, update and notification of update to maximum allowable cost list; administrative appeal procedure for challenge to maximum allowable cost list and reimbursements; reimbursement by pharmacy benefit manager to pharmacy or pharmacist in amount less than reimbursement to pharmacy benefit manager affiliate for same pharmacist services prohibited

(1)
As used in this section, the following terms shall be defined as provided in this subsection:
(a)
"Maximum allowable cost list" means a listing of drugs or other methodology used by a pharmacy benefit manager, directly or indirectly, setting the maximum allowable payment to a pharmacy or pharmacist for a generic drug, brand-name drug, biologic product or other prescription drug. The term "maximum allowable cost list" includes without limitation:
(i)
Average acquisition cost, including national average drug acquisition cost;
(ii)
Average manufacturer price;
(iii)
Average wholesale price;
(iv)
Brand effective rate or generic effective rate;
(v)
Discount indexing;
(vi)
Federal upper limits;
(vii)
Wholesale acquisition cost; and
(viii)
Any other term that a pharmacy benefit manager or a health care insurer may use to establish reimbursement rates to a pharmacist or pharmacy for pharmacist services.
(b)
"Pharmacy acquisition cost" means the amount that a pharmaceutical wholesaler charges for a pharmaceutical product as listed on the pharmacy's billing invoice.
(2)
Before a pharmacy benefit manager places or continues a particular drug on a maximum allowable cost list, the drug:
(a)
If the drug is a generic equivalent drug product as defined in 73-21-73, shall be listed as therapeutically equivalent and pharmaceutically equivalent "A" or "B" rated in the United States Food and Drug Administration's most recent version of the "Orange Book" or "Green Book" or have an NR or NA rating by Medi-Span, Gold Standard, or a similar rating by a nationally recognized reference approved by the board;
(b)
Shall be available for purchase by each pharmacy in the state from national or regional wholesalers operating in Mississippi; and
(c)
Shall not be obsolete.
(3)
A pharmacy benefit manager shall:
(a)
Provide access to its maximum allowable cost list to each pharmacy subject to the maximum allowable cost list;
(b)
Update its maximum allowable cost list on a timely basis, but in no event longer than three (3) calendar days; and
(c)
Provide a process for each pharmacy subject to the maximum allowable cost list to receive prompt notification of an update to the maximum allowable cost list.
(4)
A pharmacy benefit manager shall:
(a)
Provide a reasonable administrative appeal procedure to allow pharmacies to challenge a maximum allowable cost list and reimbursements made under a maximum allowable cost list for a specific drug or drugs as:
(i)
Not meeting the requirements of this section; or
(ii)
Being below the pharmacy acquisition cost.
(b)
The reasonable administrative appeal procedure shall include the following:
(i)
A dedicated telephone number, email address and website for the purpose of submitting administrative appeals;
(ii)
The ability to submit an administrative appeal directly to the pharmacy benefit manager regarding the pharmacy benefit management plan or through a pharmacy service administrative organization; and
(iii)
A period of less than thirty (30) business days to file an administrative appeal.
(c)
The pharmacy benefit manager shall respond to the challenge under paragraph (a) of this subsection (4) within thirty (30) business days after receipt of the challenge.
(d)
If a challenge is made under paragraph (a) of this subsection (4), the pharmacy benefit manager shall within thirty (30) business days after receipt of the challenge either:
(i)
If the appeal is upheld:
1.
Make the change in the maximum allowable cost list payment to at least the pharmacy acquisition cost;
2.
Permit the challenging pharmacy or pharmacist to reverse and rebill the claim in question;
3.
Provide the National Drug Code that the increase or change is based on to the pharmacy or pharmacist; and
4.
Make the change under item 1 of this subparagraph (i) effective for each similarly situated pharmacy as defined by the payor subject to the maximum allowable cost list; or
(ii)
If the appeal is denied, provide the challenging pharmacy or pharmacist the National Drug Code and the name of the national or regional pharmaceutical wholesalers operating in Mississippi that have the drug currently in stock at a price below the maximum allowable cost as listed on the maximum allowable cost list; or
(iii)
If the National Drug Code provided by the pharmacy benefit manager is not available below the pharmacy acquisition cost from the pharmaceutical wholesaler from whom the pharmacy or pharmacist purchases the majority of prescription drugs for resale, then the pharmacy benefit manager shall adjust the maximum allowable cost as listed on the maximum allowable cost list above the challenging pharmacy's pharmacy acquisition cost and permit the pharmacy to reverse and rebill each claim affected by the inability to procure the drug at a cost that is equal to or less than the previously challenged maximum allowable cost.
(5)
(a)
A pharmacy benefit manager shall not reimburse a pharmacy or pharmacist in the state an amount less than the amount that the pharmacy benefit manager reimburses a pharmacy benefit manager affiliate for providing the same pharmacist services.
(b)
The amount shall be calculated on a per unit basis based on the same brand and generic product identifier or brand and generic code number.
Added by Laws, 2020, ch. 395, HB 708,§ 4, eff. 1/1/2021.