1. (a) Maximum Allowable Cost.

   1. (1) Contracts between a PBM and a provider shall conform to the following requirements:

      1. (A) Identify sources of information utilized by the PBM to create and modify the PBM's maximum allowable cost price specific to the pharmacy;
      2. (B) The PBM shall provide an electronic process, including but not limited to e-mail, for its pharmacy providers to readily access the MAC list specific to that provider. Upon a provider's written request, a PBM shall furnish its MAC list to the provider in paper form or other agreed format;
      3. (C) If a provider is unable to obtain a drug from a specific regional or national wholesaler where the drug can be purchased by the dispensing pharmacy at a price below the PBM's multisource drug product reimbursement, the PBM shall provide a reasonable appeals procedure to contest the multisource drug product reimbursement amount;
      4. (D) A "reasonable appeals procedure" means a process which permits a provider or a provider's representative to contest a multisource drug product reimbursement amount based on the provider's contention that the drug is not available for purchase by the dispensing pharmacy at a price below the PBM's multisource drug product reimbursement;
      5. (E) A provider's appeal shall contain information including but not limited to the date of claim, National Drug Code number, and the identity of the national or regional wholesalers from which the drug was found to be unavailable for purchase by the provider, at or below the PBM's multisource drug product reimbursement;
   2. (2) A PBM shall permit the submission of either paper or electronic documentation to perfect an appeal. A PBM shall not require the submission of appeals on an individual claim (non-batch) basis or refuse to accept appeals from a provider's designated representative or require procedures that have the effect of obstructing or delaying the appeal process. All multisource drug product reimbursement appeals shall be properly documented.
   3. (3) Before beginning business, and as contracts are amended thereafter (including but not limited to any changes or amendments to a provider manual or other document referenced in or by a contract), each PBM shall submit to the Insurance Commissioner a certificate signed by an executive officer of the PBM attesting that the Oklahoma provider contracts utilized by such PBM satisfy the requirements of the act.
2. (b) The relationship between a PBM and an insurer or other payor is controlled by contract whereby the PBM acts on behalf of the payor to facilitate the delivery of prescription medication benefits provided by such payor. Requirements and limitations contained within the act and applicable to such payors must be understood within this payor - contractor relationship.

3. (c) Every insurer utilizing the services of a pharmacy benefit manager shall be responsible, as follows:

   1. (1) for approving all contractual documents utilized by its contracted PBMs and its retail pharmacy network to ensure compliance with the act; and

   2. (2) for conducting an annual audit of transactions and practices utilized by its contracted PBMs and members of its retail pharmacy network to ensure compliance with the act.

      1. (A) In conformity with these responsibilities and before May 1 of each year, every insurer utilizing the services of a PBM licensed in the state shall, on an annual basis, complete and submit an Annual PBM audit report to the Department.
      2. (B) The Annual PBM Audit Report shall be in the manner and form as prescribed by the Commissioner on the Department website.

Added at 32 Ok Reg 1953, eff 9-15-15

Amended at 35 Ok Reg 1744, eff 9-14-18

Amended at 37 Ok Reg 135, eff 11-1-19 (emergency)

Amended at 37 Ok Reg 1926, eff 9-11-20

Amended at 40 Ok Reg 1628, eff 9-1-23