Amendment #22 to H4891

Maximum Allowable Cost Lists

Mr. Jones of North Reading moves to amend the amendment by striking, in SECTION 36, subsections (d) and (e) of section 6 of the proposed chapter 176Y, contained in lines 975 to 1006, inclusive, and inserting in place thereof the following:-

“(d) (1) A pharmacy benefit manager shall maintain a formal internal grievance process for pharmacies, and such formal internal grievance process shall provide for adequate consideration and timely resolution of grievances. A pharmacy benefit manager’s internal grievance process shall include the following: (i) a dedicated telephone number, email address and website for the purpose of submitting a grievance; (ii) the ability to submit a grievance directly to the pharmacy benefit manager regarding the pharmacy benefits plan or program; and (iii) the ability to file a grievance within 30 business days of the qualifying event.

(2) The pharmacy benefit manager shall respond to a grievance within 30 business days of receipt of the grievance. If the pharmacy benefit manager determines as a result of the internal grievance process that the pharmacy benefit manager’s challenged conduct was not compliant with this section, the pharmacy benefit manager shall: (i) notify the pharmacy of the decision; (ii) apply the change in the maximum allowable cost effective as of the date the appeal was resolved and make the change effective for all similarly situated pharmacies subject to the maximum allowable cost list; (iii) permit the pharmacy to reverse and rebill the claim that was appealed.

(3) If the pharmacy benefit manager determines as a result of the internal grievance process that the pharmacy benefit manager’s challenged conduct was compliant with this section, the pharmacy benefit manager shall: (i) notify the pharmacy of the reason for the denial; (ii) provide the national drug code for the prescription that is the subject of the appeal; and (iii) the names of the national or regional pharmaceutical wholesalers operating in the state.

(e) A pharmacy benefit manager shall not reimburse an independent pharmacy an amount less than the amount that the pharmacy benefit manager reimburses a pharmacy benefit manager affiliate for providing the same pharmacist services.”