- (a) In responding to a MAC complaint for complaints to the State Insurance Department, the PBM shall be subject to the same time period for responding to the complaint as described in Unfair Claims Settlement Practices, 23 CAR pt. 15, for health carriers.
(b)
- (1) A pharmacy provider or a pharmacy services administrative organization (PSAO) acting on the provider’s behalf shall make reasonable efforts to exhaust any internal appeal requirements of the PBM prior to filing a complaint with the department.
- (2) However, a pharmacy provider shall not be required to exhaust internal appeal requirements of the PBM if a PBM has significantly failed to provide timely communication and timely processing of the appeal, as required under the MAC law, or has failed to abide by its MAC appeal processes as described in 23 CAR § 146-104(a)(3)(J).
- (c) A PBM shall not be held responsible for failure to timely process a communication or timely process in the event that a PSAO or pharmacy has not submitted sufficient information for the PBM to process the appeal.