(a) Before a pharmacy benefits manager or covered entity may place a drug on a maximum allowable cost list, the pharmacy benefits manager or covered entity must find that the drug is generally available for purchase by pharmacies in this state from a national or regional wholesaler.

Terms Used In Tennessee Code 56-7-3106

  • Maximum allowable cost: means the maximum amount that a pharmacy benefits manager or covered entity will reimburse a pharmacy for the cost of a drug or a medical product or device. See Tennessee Code 56-7-3102
  • Maximum allowable cost list: means a list of drugs, medical products or devices, or both medical products and devices, for which a maximum allowable cost has been established by a pharmacy benefits manager or covered entity. See Tennessee Code 56-7-3102
  • Pharmacy benefits manager: includes , but is not limited to, a health insurance issuer, managed health insurance issuer as defined in §. See Tennessee Code 56-7-3102
  • State: when applied to the different parts of the United States, includes the District of Columbia and the several territories of the United States. See Tennessee Code 1-3-105
(b) If a drug that has been placed on a maximum allowable cost list no longer meets the requirements of subsection (a), the drug shall be removed from the maximum allowable cost list by the pharmacy benefits manager or covered entity within five (5) business days after the date that the pharmacy benefits manager or covered entity becomes aware that the drug no longer meets the requirements of subsection (a).
(c) Nothing in this part shall be construed as preventing a pharmacy benefits manager or covered entity from reimbursing claims for a generic drug at the previously determined maximum allowable cost even if the pharmacy benefits manager or covered entity reimburses for the equivalent brand name drug at the contracted brand rate after confirmation by a national or regional wholesaler and by the manufacturer that the generic drug is generally unavailable for purchase from a national or regional wholesaler.
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