Montana Code 33-22-173. Maximum allowable cost — appeals process
33-22-173. Maximum allowable cost — appeals process. (1) In contracting with a pharmacy or a pharmacy services administrative organization, a plan sponsor or pharmacy benefit manager shall:
Terms Used In Montana Code 33-22-173
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Plan sponsor: has the meaning provided under section 3(16)(B) of the Employee Retirement Income Security Act of 1974, 29 U. See Montana Code 33-22-140
- Process: means a writ or summons issued in the course of judicial proceedings. See Montana Code 1-1-202
- State: when applied to the different parts of the United States, includes the District of Columbia and the territories. See Montana Code 1-1-201
(a)provide a procedure by which a pharmacy or a pharmacy services administrative organization may appeal the price of a drug or drugs on the maximum allowable cost list;
(b)provide a telephone number at which a network pharmacy may contact the pharmacy benefit manager to discuss the status of the pharmacy’s appeal; and
(c)respond to an appeal no later than 10 calendar days after the date the appeal is made.
(2)If the final determination is a denial of the pharmacy’s or the pharmacy services administrative organization’s appeal, the pharmacy benefit manager shall state the reason for the denial and provide the national drug code of an equivalent drug that is available for purchase by pharmacies in this state from national or regional wholesalers at a price that is equal to or less than the maximum allowable cost for that drug.
(3)If a pharmacy’s or a pharmacy services administrative organization’s appeal is determined to be valid by the pharmacy benefit manager, the pharmacy benefit manager shall:
(a)make an adjustment in the drug price effective on the date the appeal is resolved;
(b)make the adjustment applicable to all similarly situated network pharmacy providers as determined by the plan sponsor or the pharmacy benefit manager, as appropriate; and
(c)permit the appealing pharmacy to reverse and rebill the claim in question, using the dates of the original claim or claims.
(4)A pharmacy benefit manager shall make price adjustments to all similarly situated pharmacies within 3 days.
(5)A pharmacy or a pharmacy services administrative organization shall file its appeal within 10 calendar days from the time of denial by the pharmacy benefit manager.