1. A. A Pharmacy Benefit Manager may contract with a utilization review agent certified by the Department pursuant to A.R.S. § 20-2504 or exempt from certification under A.R.S. § 20-2502(B) to perform utilization review for pharmaceutical claims on behalf of the Pharmacy Benefit Manager.

2. B. If a Pharmacy Benefit Manager performs utilization review for a health care insurer for pharmaceutical claims, the Pharmacy Benefit Manager shall perform the duties required of a certified utilization review agent including:

   1. 1. Conducting utilization review in accordance with the utilization review plan that is on file with the Department;
   2. 2. Adopting a utilization review plan that includes a summary description of review guidelines, protocols and procedures, standards and criteria to be used in evaluating pharmaceutical services covered by the health care insurer, and the provisions by which patients or pharmacies may seek reconsideration or appeal of the decisions made by the Pharmacy Benefit Manager that complies with Arizona law;
   3. 3. Ensuring that the personnel conducting utilization review have current licenses that are in good standing and without restrictions from a state professional licensing agency in the United States;

   4. 4. Having policies and procedures to ensure that a representative of the Pharmacy Benefit Manager that conducts utilization review is available:

      1. a. To receive and send notices and acknowledgments of appeals and is reasonably accessible to patients and pharmacies in this state and the Department; and
      2. b. To receive phone calls for 40 hours each week during normal business hours;
   5. 5. Having policies and procedures to ensure that the personnel conducting utilization review will follow all applicable state and federal laws to protect the confidentiality of individual medical records; and
   6. 6. Having a copy of the materials or a description of the procedure designed to inform patients and pharmacies, as appropriate, of the requirements of the utilization review plan.

3. C. If a Pharmacy Benefit Manager performs utilization review for a health care insurer for pharmaceutical claims, the Pharmacy Benefit Manager shall comply with the appeals processes of a utilization review agent as described under A.R.S. Title 20, Chapter 15, Article 2, including:

   1. 1. Adopting processes for the review, reconsideration, and appeal of denials of pharmaceutical claims consistent with the Pharmacy Benefit Manager’s utilization review plan;

   2. 2. Providing at least the following levels of review, as applicable:

      1. a. An expedited review and expedited appeal pursuant to A.R.S. § 20-2534;
      2. b. An initial appeal pursuant to A.R.S. § 20-2535; and
      3. c. An external independent review pursuant to A.R.S. § 20-2537;
   3. 3. Providing a separate information packet complying with A.R.S. § 20-2533(H) that is approved by the Director of the Department with the member’s policy, evidence of coverage, or similar document at the time of coverage or renewal of coverage;
   4. 4. Notification to the insured, at the time of a denial, of their right to appeal and whether a voluntary internal appeal is available to them pursuant to A.R.S. § 20-2536; and
   5. 5. Ensuring that for an issue of medical necessity or appropriateness, not whether a claim or service is covered, the initial appeal process is performed as prescribed by A.R.S. § 20-2535.

Historical Note

New Section made by final rulemaking at 31 A.A.R. 4446 (November 28, 2025), effective January 4, 2026 (Supp. 25-4).