RÉSUMÉ DIGEST
ACT 167 (HB 538) 2019 Regular Session LeBas
Existing law provides criteria for auditing of pharmacy records by the following entities:
(1)Managed care companies.
(2)Insurance companies.
(3)Third-party payors.
(4)Representatives of managed care companies, including pharmacy benefit managers,
insurance companies, and third-party payors.
Prior law included a protocol for onsite audits of pharmacy records by these entities. New
law repeals all provisions relative to onsite pharmacy record audits.
New law stipulates that nothing in existing law or new law shall prohibit review of a claim
filed by a pharmacy to determine if the claim is payable or is paid correctly. Provides that
such review may require the submission of prescription copies and other documentation
related to specific claims under review, but shall not require the pharmacy to provide any
additional information not related to those claims.
Prior law required that any audit involving clinical judgment be conducted by or in
consultation with a licensed pharmacist. New law revises prior law to require that any such
audit be conducted by or in consultation with a pharmacist who is licensed in this state.
Prior law provided that no pharmacy should be subject to recoupment of any portion of the
reimbursement for the dispensed product of a prescription unless certain conditions were
met. New law revises prior law to require that these conditions occur at the point of
adjudication in order for a pharmacy to be subject to recoupment.
New law stipulates that if any entity determines that the processed or adjudicated pharmacy
claim qualifies for recoupment based upon the use of a manufacturer coupon or copay card,
then the recoupment shall come from the beneficiary of the reduction if the product is
approved by the U.S. Food and Drug Administration through the new drug application
process or abbreviated new drug application, or is an investigational drug which is a
biological product as defined in existing law.
New law repeals prior law which provided that existing law relative to pharmacy record
audits should not apply to the following:
(1)Any federally funded activity specifically preempted by law or rule.
(2)Any audit conducted pursuant to the participation of a pharmacy in the La. Medicaid
program.
Effective August 1, 2019.
(Amends R.S. 22:1856.1(B)(intro. para.), (2), (3), (7)(b), and (8), (D)(1)(intro. para.) and
(2)(intro. para.), and (F); Adds R.S. 22:1856.1(D)(3); Repeals 22:1856.1(G)(3) and (4))