Pharmacy benefit managers
- contracts with pharmacies
- maximum allowable cost pricing
(1)Intentionally left blank —Ed.
(a)In each contract between a pharmacy benefit manager and a pharmacy, the pharmacy shall be given the right to obtain from the pharmacy benefit manager, within ten days after any request, a current list of the sources used to determine maximum allowable cost pricing. The pharmacy benefit manager shall update the pricing information at least every seven days and provide a means by which contracted pharmacies may promptly review pricing updates in a format that is readily available and accessible.
(b)A pharmacy benefit manager shall maintain a procedure to eliminate products from the list of drugs subject to maximum allowable cost pricing in a timely manner in order to remain consistent with pricing changes in the marketplace.
(2)In order to place a prescription drug on a maximum allowable cost list, a pharmacy benefit manager shall ensure that:
(a)The drug is listed as “A” or “B” rated in the most recent version of the United States food and drug administration’s approved drug products with therapeutic equivalence evaluations, also known as the orange book, or has an “NR” or “NA” rating or similar rating by a nationally recognized reference; and
(b)The drug is generally available for purchase by pharmacies in this state from a national or regional wholesaler and is not obsolete.
(3)Each contract between a pharmacy benefit manager and a pharmacy must include a process to appeal, investigate, and resolve disputes regarding maximum allowable cost pricing that includes:
(a)A twenty-one-day limit on the right to appeal following the initial claim;
(b)A requirement that the appeal be investigated and resolved within twenty-one days after the appeal;
(c)A telephone number at which the pharmacy may contact the pharmacy benefit manager to speak to a person responsible for processing appeals;
(d)A requirement that a pharmacy benefit manager provide a reason for any appeal denial and the identification of the national drug code, as defined in section 10-16-122.9 (2)(f), of a drug that may be purchased by the pharmacy at a price at or below the benchmark price as determined by the pharmacy benefit manager; and
(e)A requirement that a pharmacy benefit manager make an adjustment to a date no later than one day after the date of determination. This requirement does not prohibit a pharmacy benefit manager from retroactively adjusting a claim for the appealing pharmacy or for another similarly situated pharmacy.
(4)The commissioner has the authority to enforce this section and to impose a penalty or other remedy against a pharmacy benefit manager that fails to comply with this section.
(5)The commissioner may adopt rules to implement and enforce this section.
Section 10-16-122.6 — Pharmacy benefit managers - contracts with pharmacies - maximum allowable cost pricing - enforcement - rules,
https://leg.colorado.gov/sites/default/files/images/olls/crs2023-title-10.pdf (accessed Oct. 20, 2023).