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ENGROSSED SENATE
BILL NO. 993 By: Gollihare and Jech of the
Senate
and
Stinson of the House
An Act relating to pharmacy benefit s managers;
amending 59 O.S. 2021, Sections 356.1, 356.2, 356.3,
as amended by Sections 1, 2, and 3, Chapter 332,
O.S.L. 2024, and 356.4 (59 O.S. Supp. 2024, Sections
356.1, 356.2, and 356.3), which relate to
definitions, pharmacy audit requirements, appeals
process, and prohibited extrapolation audit;
modifying notice contents; prohibiting assessment of
certain fines under certain circumstances; expanding
certain claim limits; establishing requirements for
preliminary audit findings reports; requiring
provision of certain final audit results within a
certain time period; updating statutory reference;
requiring certain no tification to Attorney General in
certain circumstances; expanding requirement for
initiation of certain audit; lengthening time period
for certain preliminary report; allowing certain
extension request; shortening certain time period for
certain final report; establishing requirements for
audit findings report; modifying definition; defining
terms; requiring certain tolling in certain declared
disaster; providing certain exceptions; amending 59
O.S. 2021, Sections 357, 358, and 360 , as amended by
Sections 4, 5, and 6, Chapter 332, O.S.L. 2024 (59
O.S. Supp. 2024, Sections 357, 358, and 360), which
relate to definitions, pharmacy benefits management
licensure, and pharmacy benefit s manager contractual
duties; modifying notice contents; defining terms;
updating statutory references; requiring certain time
period of tolling in certain declared disaster;
requiring certain documented proof by certain
pharmacy benefits managers; establishing certain
denial for certain appeals; prohibiting certain
collection of additional monies by certain pharmacy
benefits managers; establishing certain filing period
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after lifting of disaster declaration; prohibiting
certain denials; updating statutory language;
providing for codification; and declaring an
emergency.
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1. AMENDATORY 59 O.S. 2021, Section 356.1, as
amended by Section 1, Chapter 332, O.S.L. 2024 (59 O.S. Supp. 2024,
Section 356.1), is amended to read as follows:
Section 356.1. A. For purposes of the Pharmacy Audit Integrity
Act, “pharmacy benefits manager ”:
1. “Audit” means any review, inspection, or analysis conducted
by a pharmacy benefits manager (PBM) or its representative of a
pharmacy’s records, practices, or compliance with contractual
obligations;
2. “Disaster declaration ” and “declared disaster” mean a
declaration issued by the Governor or the President of the United
States for an event that qualifies as a disaster including, but not
limited to, a flood, tornado, earth quake, wildfire, terrorist
attack, or other catastrophic event; and
3. “Pharmacy benefits manager ” or “PBM” shall have the same
meaning as in Section 6960 of Title 36 of the Oklahoma Statutes.
B. The purpose of the Pharmacy Audit Integrity Act is to
establish minimum and uniform standards and criteria for the audit
of pharmacy records by or on behalf of certain entities.
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C. The Pharmacy Audit Integrity Act shall apply to any audit of
the records of a pharmacy conducted by a managed care company,
nonprofit hospital, medical service organization, insurance company,
third-party payor, pharmacy benefits manager, a health program
administered by a department of this state, or any entity that
represents these companies, groups, or departments.
D. The Attorney General may promulgate rules to implement the
provisions of the Pharmacy Audit Integrity Act.
SECTION 2. AMENDATORY 59 O.S. 2021, Section 356.2, as
amended by Section 2, Chapter 332, O.S.L. 2024 (59 O.S. Supp. 2024,
Section 356.2), is amended to read as follows:
Section 356.2. A. The entity conducting an audit of a pharmacy
shall:
1. Identify and specifically describe the audit and appeal
procedures in the pharmacy contract. Prescription claim
documentation and record-keeping recordkeeping requirements shall
not exceed the requirements set forth by the Oklahoma Pharmacy Act
or other applicable state or federal laws or regulations;
2. Give the pharmacy written notice by certified letter to the
pharmacy and the pharmacy ’s contracting agent, including
identification of specific prescription numbers and, fill dates,
drug names, and National Drug Code (NDC) numbers to be audited, at
least fourteen (14) calendar days prior to conducting the audit,
including, but not lim ited to, an on-site audit, a desk audit, or a
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wholesale purchase audit, request for documentation related to the
dispensing of a prescription drug , or any reimbursed activity by a
pharmacy provider; provided, however, that wholesale purchase audits
shall require a minimu m of thirty (30) calendar days ’ written
notice. For an on-site audit, the audit date shall be the date the
on-site audit occurs. For all other audit types, the audit date
shall be the date the pharmacy provides the documentation requested
in the audit notice. The pharmacy shall have the opportunity to
reschedule the audit no more than seven (7) calendar days from the
date designated on the original audit notification;
3. Not interfere with the delivery of pharmacist services to a
patient and shall utili ze every reasonable effort to minimize
inconvenience and disruption to pharmacy operations during the audit
process;
4. Conduct any audit involving clinical or professional
judgment by means of or in consultation with a licensed pharmacist;
5. Not consider as fraud any clerical or record-keeping
recordkeeping error, such as a typographical error, scrivener ’s
error or computer error, including, but not limited to, a
miscalculated day supply, incorrectly billed prescription written
date or prescription orig in code, and such errors shall not be
subject to recoupment. The pharmacy shall have the right to submit
amended claims electronically to correct clerical or record-keeping
recordkeeping errors in lieu of recoupment. To the extent that an
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audit results in the identification of any clerical or record-
keeping recordkeeping errors such as typographical errors,
scrivener’s errors or computer errors in a required document or
record, the pharmacy shall not be subject to recoupment of funds by
the pharmacy benefits manager unless the pharmacy benefits manager
can provide proof of intent to commit fraud. A person shall not be
subject to criminal penalties for errors provided for in this
paragraph without proof of intent to commit fraud;
6. Permit a pharmacy to use the records of a hospital,
physician, or other authorized practitioner of the healing arts for
drugs or medicinal supplies written or transmitted by any means of
communication for purposes of validating the pharmacy record with
respect to orders or refi lls of a legend or narcotic drug;
7. Not include the dispensing fee amount or the actual invoice
cost of the prescription dispensed in a finding of an audit
recoupment unless a prescription was not actually dispensed or a
physician denied authorization of a dispensing order;
8. Audit each pharmacy under identical standards, regularity
and parameters as other similarly situated pharmacies and all
pharmacies owned or managed by the pharmacy benefits manager
conducting or having conducted the audit;
9. Not exceed one (1) year from the date the claim was
submitted to or adjudicated by a managed care company, nonprofit
hospital or medical service organization, insurance company, third -
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party payor, pharmacy benefits manager, a health program
administered by a department of this state, or any entity that
represents the companies, groups, or departments for the period
covered by an audit;
10. Not schedule or initiate an audit during the first seven
(7) calendar days of any month unless otherwise consented to by t he
pharmacy;
11. Disclose to any plan sponsor whose claims were included in
the audit any money recouped in the audit;
12. Not require pharmacists to break open packaging labeled
“for single-patient-use only”. Packaging labeled “for single-
patient-use only” shall be deemed to be the smallest package size
available; and
13. Upon recoupment of funds from a pharmacy, refund first to
the patient the portion of the recovered funds that were originally
paid by the patient, provided such funds were part of the
recoupment; and
14. Not assess a fine, penalty, or any other financial
requirement on the pharmacy or pharmacist for any prescription
audited unless there is a valid recoupment under the Pharmacy Audit
Integrity Act.
B. 1. Any entity tha t conducts wholesale purchase review
during an audit of a pharmacist or pharmacy shall not require the
pharmacist or pharmacy to provide a full dispensing report.
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Wholesaler invoice reviews shall be limited to verification of
purchase inventory specific to the pharmacy claims paid by the
health benefits plan or pharmacy benefits manager conducting the
audit.
2. Any entity conducting an audit shall not identify or label a
prescription claim as an audit discrepancy when:
a. the National Drug Code for the di spensed drug is in a
quantity that is a subunit or multiple of the drug
purchased by the pharmacist or pharmacy as supported
by a wholesale invoice,
b. the pharmacist or pharmacy dispensed the correct
quantity of the drug according to the prescription,
and
c. the drug dispensed by the pharmacist or pharmacy
shares all but the last two digits of the National
Drug Code of the drug reflected on the supplier
invoice.
3. An entity conducting an audit shall accept as evidence,
subject to validation, to support t he validity of a pharmacy claim
related to a dispensed drug:
a. redacted copies of supplier invoices in the
pharmacist’s or pharmacy’s possession, or
b. invoices and any supporting documents from any
supplier as authorized by federal or state law to
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transfer ownership of the drug acquired by the
pharmacist or pharmacy.
4. An entity conducting an audit shall provide, no later than
five (5) calendar days after the date of a request by the pharmacist
or pharmacy, all supporting documents the pharmacist ’s or pharmacy’s
purchase suppliers provided to the health benefits plan issuer or
pharmacy benefits manager.
C. A pharmacy shall be allowed to provide the pharmacy ’s
computerized patterned medical records or the records of a hospital,
physician, or other authorized practition er of the healing arts for
drugs or medicinal supplies written or transmitted by any means of
communication for purposes of supporting the pharmacy record with
respect to orders or refills of a legend or narcotic drug.
D. The entity conducting the audit shall not audit more than
fifty prescriptions, with specific date of service, per calendar
year PBM or its agent shall not exceed an annual limit of one
hundred prescription claims with a specific prescription number and
date of fill per calendar year . The annual limit to the number of
prescription claims audited shall be inclusive of all audits by a
PBM or its agent, including any prescription -related documentation
requests from the health insurer, pharmacy benefits manager or any
third-party company conducting audits on behalf of any health
insurer or pharmacy benefits manager during a calendar year.
Notwithstanding the annual limit on the number of prescription
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claims per calendar year pursuant to this section, no PBM or its
agent shall exceed more than fifty prescription claims with a
specific prescription number and date of fill on an individual
audit.
E. If paper copies of records are requested by the entity
conducting the audit, the entity shall pay twenty -five cents ($0.25)
per page to cover the costs incurred by the pharmacy. The entity
conducting the audit shall provide the pharmacy with accurate
instructions, including any required form for obtaining
reimbursement for the copied records.
F. The entity conducting the audit shall:
1. Deliver a preliminary audit findings report to the pharmacy
and the pharmacy’s contracting agent within forty -five (45) calendar
days of conducting the audit;
2. Allow the pharmacy at least ninety (90) calendar days
following receipt of the preliminary audit findings report in which
to produce documentation to address any discrepancy found during the
audit; provided, however, a pharmacy may request an extension, not
to exceed an additional forty -five (45) calendar days;
3. Deliver a final audit findings report to the pharmacy and
the pharmacy’s contracting agent signed by the auditor within ten
(10) calendar days after receipt of additional documentation
provided by the pharmacy, as provided for in Section 356.3 of this
title;
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4. Allow the pharmacy to reverse and resubmit claims
electronically within thirty (30) calendar days of receipt of the
final audit report in lieu of the auditing entity recouping
discrepant claim amounts from the pharmacy;
5. Not recoup any disputed funds until after final disposition
of the audit findings, including the appeals process as provided for
in Section 356.3 of this title; and
6. Not accrue interest during the audit and appeal period ;
7. Ensure that each preliminary audit findings report required
by this section inclu des:
a. specific prescription numbers, fill dates, drug names,
and NDC numbers, and
b. the date of receipt of documents from the pharmacy,
the pharmacy’s contracting agent, or any other source
associated with the audit .
G. Each entity conducting an audit shall provide a copy of the
final audit results, and a final audit report upon request, after
completion of any review process to the plan sponsor
In addition to the requirements for a preliminary audit findings
report in this paragraph, the final audit fi ndings report shall
include any additional documentation that was submitted to the
auditing entity;
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8. Provide the plan sponsor a copy of the final audit results
within thirty (30) calendar days of the final disposition of the
audit; and
9. At the request of the plan s ponsor, provide a copy of the
final audit findings report within thirty (30) calendar days of the
request.
H. G. 1. The full amount of any recoupment on an audit shall
be refunded to the plan sponsor. Except as provided for in
paragraph 2 of this subsection, a charge or assessment for an audit
shall not be based, directly or indirectly, on amounts recouped.
2. This subsection does not prevent the entity conducting the
audit from charging or assessing the responsible party, directly or
indirectly, based on amounts recouped if both of the following
conditions are met:
a. the plan sponsor and the entity conducting the audit
have a contract that explicitly states the percentage
charge or assessment to the plan sponsor, and
b. a commission to an agent or employee of the entity
conducting the audit is not based, directly or
indirectly, on amounts recouped.
I. H. Unless superseded by state or federal law, auditors shall
only have access to previous audit reports on a particular pharmacy
conducted by the auditin g entity for the same pharmacy benefits
manager, health plan or insurer. An auditing vendor contracting
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with multiple pharmacy benefits managers or health insurance plans
shall not use audit reports or other information gained from an
audit on a pharmacy to conduct another audit for a different
pharmacy benefits manager or health insurance plan.
J. Sections A through I
I. Paragraph 2 of subsection A of this section through
subsection D of this section, and paragraph 1 through paragraph 7 of
subsection F of this section shall not apply to any audit initiated
based on or that involves suspicion of fraud, willful
misrepresentation, or abuse.
K. J. If the Attorney General, after notice and opportunity for
hearing, finds that the entity conduct ing the audit failed to follow
any of the requirements pursuant to the Pharmacy Audit Integrity
Act, the audit shall be considered null and void. Any monies
recouped from a null and void audit shall be returned to the
affected pharmacy within fourteen (14) calendar days . Any violation
of this section by a pharmacy benefits manager or auditing entity
shall be deemed a violation of the Pharmacy Audit Integrity Act.
SECTION 3. AMENDATORY 59 O.S. 2021, Section 356.3, as
amended by Section 3, Chapter 332, O.S.L. 2024 (59 O.S. Supp. 2024,
Section 356.3), is amended to read as follows:
Section 356.3. A. Each entity conducting an audit shall
establish a written appeals process under which a pharmacy may
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appeal an unfavorable preliminary audit report a nd/or final audit
report to the entity.
B. Following an appeal, if the entity finds that an unfavorable
audit report or any portion thereof is unsubstantiated, the entity
shall dismiss the audit report or the unsubstantiated portion of the
audit report without any further action.
C. Any final audit report, following the final audit appeal
period, with a finding of fraud or willful misrepresentation shall
be referred to the district attorney having proper jurisdiction or
the Attorney General for prosecutio n upon completion of the appeals
process. If a finding of fraud or willful misrepresentation is
referred to a district attorney under this subsection, the auditing
entity shall notify the Attorney General as to whom the referral was
made and the date the referral was made.
D. For any audit initiated based on or that involves suspicion
of fraud, willful misrepresentation, or abuse, the auditing entity
shall provide, in writing, at the time of the audit, a clear and
conspicuous declaration to the pharmacy b eing audited that the audit
is being conducted under suspicion of fraud, willful
misrepresentation, or abuse and a statement of facts that supports
the reasonable suspicion. The entity conducting an audit based on
suspicion of fraud, willfu l misrepresentation, or abuse shall
provide a copy of the clear and conspicuous declaration required by
this subsection to the pharmacy ’s contracting agent by certified
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mail within five (5) business days of notifying the pharmacy of an
audit pursuant to this section.
E. The entity conducting an audit based on suspicion of fraud,
willful misrepresentation, or abuse shall:
1. Deliver a preliminary findings report to the pharmacy and
the pharmacy’s contracting agent within ninety (90) calendar days of
notification of the audit;
2. Allow the pharmacy at least ninety (90) calendar days
following the receipt of the preliminary audit findings report in
which to produce documentation to address any discrepancy found
during the audit. A pharmacy may request an extension, not to
exceed an additional forty -five (45) calendar days;
3. Deliver a final audit findings report to the pharmacy and
the pharmacy’s contracting agent signed by the auditor within thirty
(30) calendar days after receipt of additional documentat ion
provided by the pharmacy;
4. Allow the pharmacy to reverse and resubmit claims
electronically within thirty (30) calendar days of receipt of the
final audit report in lieu of the auditing entity recouping
discrepant claim amounts from the pharmacy;
5. Not recoup any disputed funds until after the final
disposition of the audit findings, including the appeals process
pursuant to this section;
6. Not accrue interest during the audit and appeal period;
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7. Ensure that each preliminary audit findings rep ort submitted
pursuant to this section includes:
a. specific prescription numbers, fill dates, drug names,
and NDC numbers, and
b. the date of receipt of documents from the pharmacy,
the pharmacy’s contracting agent, or any other source
associated with the audit;
8. Ensure that each final audit findings report includes any
additional documentation that was submitted to the auditing entity;
9. Provide the plan sponsor a copy of the final audit results
within thirty (30) calendar days of the final dispositi on of the
audit; and
10. At the request of the plan sponsor, provide a copy of the
final audit report within thirty (30) calendar days of the request.
F. Any entity conducting an audit that is based on or involves
suspicion of fraud, willful misrepresentation, or abuse shall
provide to the Office of the Attorney General:
1. Notice at least two (2) calendar days prior to beginning
performance of an audit pursuant to this section;
2. A preliminary report within thirty (30) calendar days of
performing the audit five (5) business days of providing a copy of
the preliminary report to the pharmacy and the pharmacy ’s
contracting agent pursuant to this section . The auditing entity may
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request an extension from the Attorney General, not to exceed an
additional ninety (90) cale ndar days; and
3. A final report within thirty (30) ten (10) calendar days
following the closure of the final appeal period for an audit
performed pursuant to this section.
a. The final report for the Office of the Attorney
General shall include the name of each plan sponsor
whose claims were included in the audit recover, the
amount of funds recouped on behalf of the plan, the
date the plan sponsor was notified of the recoupment,
the date the plan sponsor was paid any recoupment, and
the name and contact information for the
representative of the plan sponsor who was notified of
the recoupment at issue in an audit pursuant to this
section.
b. The auditing entity may request an extension from the
Attorney General, not to exceed an additional t en (10)
calendar days.
F. G. The Attorney General, authorized employees, and examiners
shall have access to any pharmacy benefits manager ’s files and
records that may relate to an any audit including, but not limited
to, an audit that is based on or involves suspicion of fraud,
willful misrepresentation, or abuse.
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G. H. The Attorney General may levy a civil or administrative
fine of not less than One Hundred Dollars ($100.00) and not greater
than Ten Thousand Dollars ($10,000.00) for each violation of thi s
section and assess any other penalty or remedy authorized by law.
SECTION 4. AMENDATORY 59 O.S. 2021, Section 356.4, is
amended to read as follows:
Section 356.4. A. For the purposes of the Pharmacy Audit
Integrity Act, “extrapolation audit” means an audit of a sample of
prescription drug benefit claims submitted by a pharmacy to the
entity conducting the audit that is then used to estimate audit
results for a larger batch or group of claims not reviewed by the
auditor, including refills not listed in the written notification in
accordance with paragraph 2 of subsection A of Section 356.2 of this
title.
B. The entity conducting the audit shall not use the accounting
practice of extrapolation in calculating recoupments or penalties
for audits.
SECTION 5. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 356.6 of Title 59, unless there
is created a duplication in numbering, reads as follows:
A. Notwithstanding any other provis ion of law, the ability of a
pharmacy benefits manager (PBM) to initiate, continue, or conclude
an audit of a pharmacy shall be tolled for the duration of a
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declared disaster and for an additional period of thirty (30)
calendar days following the termination of a declare d disaster.
Such requirement shall apply only to the pharmacies located
within the geographical boundaries of the county or counties
affected by the declared disaster.
B. The provisions of this section shall apply to all PBMs
operating within this state, and to all audits conducted pursuant to
contracts between PBMs and pharmacies.
C. This section shall not apply to:
1. Audits conducted for suspected fraudulent activity if
documented evidence of such activity exists; or
2. Audits required to comply with federal or state law
unrelated to the contractual relationship between a PBM and a
pharmacy.
D. Nothing in this section shall be construed to prohibit a
pharmacy from voluntarily agreeing to continue or complete an audit
during the tolling period, provided such agreement is documented in
writing and signed by both parties.
E. A PBM may submit a request to the Attorney General to
continue or complete an audit during the tolling period, which the
Attorney General may grant at his or her sole discretion. A ny PBM
granted such permission by the Attorney General shall do so pursuant
to the requirements of this act.
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SECTION 6. AMENDATORY 59 O.S. 2021, Section 357, as
amended by Section 4, Chapter 332, O.S.L. 2024 (59 O.S . Supp. 2024,
Section 357), is amended to read as follows:
Section 357. A. As used in Sections 357 through 360 of this
title and Section 8 of this act :
1. “Covered entity” means a nonprofit hospital or medical
service organization, for -profit hospital or medical servi ce
organization, insurer, health benefit plan, health maintenance
organization, health program administered by the state in the
capacity of providing health coverage, or an employer, labor union,
or other group of persons that provides healt h coverage to persons
in this state. This term does not include a health benefit plan
that provides coverage only for accidental injury, specified
disease, hospital indemnity, disability income, or other limited
benefit health insurance policies and contracts that do no t include
prescription drug coverage;
2. “Covered individual” means a member, participant, enrollee,
contract holder or policy holder or beneficiary of a covered entity
who is provided health coverage by the covered entity. A covered
individual includes any dependent or other person provided health
coverage through a policy, contract or plan for a covered
individual;
3. “Department” means the Insurance Department;
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4. “Maximum allowable cost ”, “MAC”, or “MAC list” means the
list of drug products delineat ing the maximum per-unit reimbursement
for multiple-source prescription drugs, medical product, or device;
5. “Multisource drug product reimbursement ” (reimbursement)
means the total amount paid to a pharmacy inclusive of any reduction
in payment to the pharmacy, excluding prescription dispense fees;
6. “Office” means the Office of the Attorney General;
7. “Pharmacy benefits management ” means a service provided to
covered entities to facilitate the provision of prescription drug
benefits to covered indiv iduals within the state, including
negotiating pricing and other terms with drug manufacturers and
providers. Pharmacy benefits management may include any or all of
the following services:
a. claims processing, retail network management and
payment of claims to pharmacies for prescription drugs
dispensed to covered individuals,
b. clinical formulary development and management
services, or
c. rebate contracting and administration;
8. “Pharmacy benefits manager ” or “PBM” means a person,
business, or other e ntity that performs pharmacy benefits
management. The term shall include any business or entity licensed
by the Insurance Department to perform PBM services, or a person or
entity acting on behalf of a PBM in a contractual or employment
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relationship in the performance of pharmacy benefits management for
a managed care company, nonprofit hospital, medical service
organization, insurance company, third -party payor, or a health
program administered by an agency or department of this state;
9. “Plan sponsor” means the employers, insurance companies,
unions and health maintenance organizations or any other entity
responsible for establishing, maintaining, or administering a health
benefit plan on behalf of covered individuals; and
10. “Provider” means a pharmacy licensed by the State Board of
Pharmacy, or an agent or representative of a pharmacy, including,
but not limited to, the pharmacy ’s contracting agent, which
dispenses prescription drugs or devices to covered individuals.
B. Nothing in the definition of pharmacy benefits management or
pharmacy benefits manager in the Patient ’s Right to Pharmacy Choice
Act, Pharmacy Audit Integrity Act, or Sections 357 through 360 of
this title, or Section 8 of this act shall deem an employer a
“pharmacy benefits manager” pharmacy benefits manager of its own
self-funded health benefit plan, except, to the extent permitted by
applicable law, where the employer, without the utilization of a
third party and unrelated to the employer ’s own pharmacy:
a. negotiates
1. Negotiates directly with drug manufacturers ,;
b. processes
2. Processes claims on behalf of its members ,; or
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c. manages
3. Manages its own retail network of pharmacies.
SECTION 7. AMENDATORY 59 O.S. 2021, Section 358, as
amended by Section 5, Chapter 332, O.S.L. 2024 (59 O.S. Supp. 2024,
Section 358), is amended to read as follows:
Section 358. A. In order to provide pharmacy benefits
management or any of the services included under the definition of
pharmacy benefits management in this state, a pharmacy benefits
manager or any entity acting as one in a contractual or employment
relationship for a covered entity shall first obtain a license from
the Insurance Department, and the Department may charge a fee for
such licensure.
B. The Department shall establish, by regulation, licensure
procedures, required disclosures for pharmacy benefits managers
(PBMs) and other rules as may be necessary for carrying out and
enforcing the provisions of this title. The licensure procedures
shall, at a minimum, include the completion of an application form
that shall include the name and address of an agent for service of
process, the payment of a requisite fee, and evidence of the
procurement of a surety bond.
C. The Department or the Of fice of the Attorney General may
subpoena witnesses and information. Its compliance officers may
take and copy records for investigative use and prosecutions.
Nothing in this subsection shall limit the Office of the Attorney
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General from using its investigative demand authority to investigate
and prosecute violations of the law.
D. The Department may suspend, revoke or refuse to issue or
renew a license for noncompliance with any of the provisions hereby
established or with the rules promulgated by the D epartment; for
conduct likely to mislead, deceive or defraud the public or the
Department; for unfair or deceptive business practices or for
nonpayment of an application or renewal fee or fine. The Department
may also levy administrative fines for each count of which a PBM has
been convicted in a Department hearing.
E. 1. The Office of the Attorney General , after notice and
opportunity for hearing, may instruct the Insurance Commissioner
that the PBM’s license be censured, suspended, or revoked for
conduct likely to mislead, deceive, or defraud the public or the
State of Oklahoma; or for unfair or deceptive business practices, or
for any violation of the Patient’s Right to Pharmacy Choice Act, the
Pharmacy Audit Integrity Act, or Sections 357 through 360 of this
title, or Section 8 of this act . The Office of the Attorney General
may also levy administrative fines for each count of which a PBM has
been convicted following a hearing before the Attorney General. If
the Attorney General makes such instructio n, the Commissioner shall
enforce the instructed action within thirty (30) calendar days.
2. In addition to or in lieu of any censure, suspension, or
revocation of a license by the Commissioner, the Attorney General
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may levy a civil or administrative fine of not less than One Hundred
Dollars ($100.00) and not greater than Ten Thousand Dollars
($10,000.00) for each violation of this subsection and/or assess any
other penalty or remedy authorized by this section. For purposes of
this section, each day a PBM fails to comply with an investigation
or inquiry may be considered a separate violation.
F. The Attorney General may promulgate rules to implement the
provisions of Sections 357 through 360 of this title and Section 8
of this act.
SECTION 8. AMENDATORY 59 O.S. 2021, Section 360, as
amended by Section 6, Chapter 332, O.S.L. 2024 (59 O.S. Supp. 2024,
Section 360), is amended to read as follows:
Section 360. A. The pharmacy benefits manager shall, with
respect to contracts between a pharmacy benefits manager and a
provider, including a pharmacy service administrative organization:
l. Include in such contracts the specific sources utilized to
determine the maximum allowable cost (MAC) pricing of the pharmacy,
update MAC pricing at least every sev en (7) calendar days, and
establish a process for providers to readily access the MAC list
specific to that provider;
2. In order to place a drug on the MAC list, ensure that the
drug is listed as “A” or “B” rated in the most recent version of the
FDA’s United States Food and Drug Administration (FDA) Approved Drug
Products with Therapeutic Equivalence Evaluations, also known as the
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Orange Book, and the drug is generally available for purchase by
pharmacies in the state from national or regional wholesaler s and is
not obsolete;
3. Ensure dispensing fees are not included in the calculation
of MAC price reimbursement to pharmacy providers;
4. Provide a reasonable administration appeals procedure to
allow a provider, a provider ’s representative and a pharmacy service
administrative organization to contest reimbursement amounts within
fourteen (14) calendar days of the final adjusted payment date. The
pharmacy benefits manager shall not prevent the pharmacy or the
pharmacy service administrative organization from filing
reimbursement appeals in an electronic batch format. The pharmacy
benefits manager must respond to a provider, a provider ’s
representative and a pharmacy service administrative organization
who have contested a reimbursement amo unt through this procedure
within ten (10) calendar days. The pharmacy benefits manager must
respond in an electronic batch format to reimbursement appeals filed
in an electronic batch format. The pharmacy benefits manager shall
not require a pharmacy or pharmacy servi ces administrative
organization to log into a system to upload individual claim appeals
or to download individual appeal responses. If a price update is
warranted, the pharmacy benefits manager shall make the change in
the reimbursement amo unt, permit the dispensing pharmacy to reverse
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and rebill the claim in question, and make the reimbursement amount
change retroactive and effective for all contracted providers; and
5. If a below-cost reimbursement appeal is denied, the PBM
shall provide the reason for the denial, including the National Drug
Code (NDC) number from, and the name of, the specific national or
regional wholesalers doing business in this state where the drug is
currently in stock and available for purchase by the dispensing
pharmacy at a price below the PBM’s reimbursement price. The PBM
shall include documented proof from the specific national or
regional wholesalers doing business in this state showing that the
drug is currently in stock and available for purchase by the
dispensing pharmacy at a price below the PBM ’s reimbursement price.
If the NDC number provided by the pharmacy benefits manager is not
available below the acquisition cost obtained from the
pharmaceutical wholesaler from whom the dispensing pharmacy
purchases the majority of the prescription drugs that are dispensed,
the pharmacy benefits manager shall immediately adjust the
reimbursement amount, permit the dispensing pharmacy to reverse and
rebill the claim in question, and make the reimbursement amount
adjustment retroacti ve and effective for all contracted providers ;
6. Any appeal that results in an increase in the reimbursement
from the PBM that continues to be below the pharmacy’s acquisition
cost shall be considered a denial under this section. Any deni al of
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an appeal shall follow the requirements of paragraph 5 of this
subsection; and
7. The PBM shall not require a pharmacy to collect additional
monies following a successful below -cost reimbursement appeal from
any person or entity other than the PBM who adjudicated the drug
claim, including the patient or plan sponsor .
B. The reimbursement appeal requirements in this section shall
apply to all drugs, medical products, or devices reimbursed
according to any payment methodology, including, but not limit ed to:
1. Average acquisition cost, including the National Average
Drug Acquisition Cost;
2. Average manufacturer price;
3. Average wholesale price;
4. Brand effective rate or generic effective rate;
5. Discount indexing;
6. Federal upper limits;
7. Wholesale acquisition cost; and
8. Any other term that a pharmacy benefits manager or an
insurer of a health benefit plan may use to establish reimbursement
rates to a pharmacist or pharmacy for pharmacist services.
C. The pharmacy benefits manager shal l not place a drug on a
MAC list, unless there are at least two therapeutically equivalent,
multiple-source drugs, generally available for purchase by
dispensing retail pharmacies from national or regional wholesalers.
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D. In the event that a drug is placed on the FDA Dr ug Shortages
Database, pharmacy benefits managers shall reimburse claims to
pharmacies at no less than the wholesale acquisition cost for the
specific NDC number being dispensed.
E. The pharmacy benefits manager shall not require
accreditation or licensing of providers, or any entity licensed or
regulated by the State Board of Pharmacy, other than by the State
Board of Pharmacy or federal government entity as a condition for
participation as a network provider.
F. A pharmacy or pharmacist may decline to p rovide the
pharmacist clinical or dispensing services to a patient or pharmacy
benefits manager if the pharmacy or pharmacist is to be paid less
than the pharmacy’s cost for providing the pharmacist clinical or
dispensing services.
G. The pharmacy benefits manager shall provide a dedicated
telephone number, email address and names of the personnel with
decision-making authority regarding MAC appeals and pricing.
SECTION 9. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 360.1 of Title 59, unless there
is created a duplication in numbering, reads as follows:
A. If a disaster declaration is issued for a county in this
state, the time period for a provider, a provider ’s representative,
or a pharmacy service administrative organization to file a below -
cost reimbursement appeal pursuant to Section 360 of Title 59 of the
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Oklahoma Statutes shall be tolled for the duration of the disaster
declaration.
B. Upon the expiration of the disaster declaration, the to lling
of the filing period for below -cost reimbursement appeals shall
continue for an additional thirty (30) calendar days. Afterward,
the time period for filing a below -cost reimbursement appeal, as
otherwise provided under state law, shal l resume.
C. The tolling provisions of this section shall apply only to
continuing counties included in the declared disaster area and to
below-cost reimbursement appeals arising from claims impacted during
the time period of the declared disaster.
D. A pharmacy benefi ts manager (PBM) shall not deny a below -
cost reimbursement appeal on timeliness if such appeal is filed
during the tolled period provided in this section.
E. The Attorney General may promulgate rules to implement the
provisions of this act.
SECTION 10. It being immediately necessary for the preservation
of the public peace, health or safety, an emergency is hereby
declared to exist, by reason whereof this act shall take effect and
be in full force from and after its passage and approval.
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Passed the Senate the 25th day of March, 2025.
Presiding Officer of the Senate
Passed the House of Representatives the ____ day of __________,
2025.
Presiding Officer of the House
of Representatives