(a) A pharmacy benefit 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 ten 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 benefit manager must respond with notice that the challenge has been denied or sustained within 10 calendar days of the contracted pharmacy making the claim for which an appeal has been submitted.
(b) At the beginning of the term of a network provider’s contract, and upon renewal, a pharmacy benefit manager must provide to network providers a telephone number or e-mail address at which a network provider can contact the pharmacy benefit manager to process an appeal under this section.
(c) If an appeal is denied, the pharmacy benefit manager must provide the reason for the denial and the name and the national drug code number from national or regional wholesalers operating in Delaware.
(d) If the appeal is sustained, the pharmacy benefits manager shall make the price correction, permit the reporting pharmacy to reverse and rebill the appealed claim, and make the price correction effective for all similarly situated pharmacies from the date of the approved appeal.
80 Del. Laws, c. 245, § 1.
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