Oklahoma 2025 Regular Session

Oklahoma Senate Bill SB993 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1	1
2	2
3		-	SB993 HFLR Page 1
4		-	BOLD FACE denotes Committee Amendments. 1
	3	+	Req. No. 13515 Page 1 1
5	4		2
6	5		3
7	6		4
8	7		5
9	8		6
10	9		7
11	10		8
12	11		9
13	12		10
14	13		11
15	14		12
16	15		13
17	16		14
18	17		15
19	18		16
20	19		17
21	20		18
22	21		19
23	22		20
24	23		21
25	24		22
26	25		23
27	26		24
28	27
29		-	HOUSE OF REPRESENTATIVES - FLOOR VERSION
30		-
31	28		STATE OF OKLAHOMA
32	29
33	30		1st Session of the 60th Legislature (2025)
34	31
35	32		COMMITTEE SUBSTITUTE
36	33		FOR ENGROSSED
37	34		SENATE BILL NO. 993 By: Gollihare and Jech of the
38	35		Senate
39	36
40	37		and
41	38
42	39		Stinson of the House
	40	+
	41	+
43	42
44	43
45	44
46	45
47	46		COMMITTEE SUBSTITUTE
48	47
49	48		An Act relating to pharmacy benefit s managers;
50	49		amending 59 O.S. 2021, Sections 356.1, 356.2, 356.3,
51	50		as amended by Sections 1, 2, and 3, Chapter 332,
52	51		O.S.L. 2024, and 356.4 (59 O.S. Supp. 2024, Sections
53	52		356.1, 356.2, and 356.3), which relate to
54	53		definitions, pharmacy audit requirements, appeals
55	54		process, and prohibited extrapolation audit;
56	55		modifying notice contents; prohibiting assessment of
57	56		certain fines under certain circumstances; expanding
58	57		certain claim limits; establishing requirements for
59	58		preliminary audit findings reports; requiring
60	59		provision of certain final audit results within a
61	60		certain time period; updating statutory reference;
62	61		requiring certain notification to Attorney General in
63	62		certain circumstances; expanding requirement for
64	63		initiation of certain audit; lengthening time period
65	64		for certain preliminary report; allowing certain
66	65		extension request; shortening certain time period for
67	66		certain final report; establishing requirements for
68	67		audit findings report; modifying definition; defining
69	68		terms; requiring certain tolling in certain declared
70	69		disaster; providing certain exceptions; amending 59
71	70		O.S. 2021, Sections 357, 358, and 360 , as amended by
72	71		Sections 4, 5, and 6, Chapter 332, O.S.L. 2024 (59
73	72		O.S. Supp. 2024, Sections 357, 358, and 360), which
74	73		relate to definitions, pharmacy benefits management
75	74		licensure, and pharmacy benefits manager contractual
76	75
77		-	SB993 HFLR Page 2
78		-	BOLD FACE denotes Committee Amendments. 1
	76	+	Req. No. 13515 Page 2 1
79	77		2
80	78		3
81	79		4
82	80		5
83	81		6
84	82		7
85	83		8
86	84		9
87	85		10
88	86		11
89	87		12
90	88		13
91	89		14
92	90		15
93	91		16
94	92		17
95	93		18
96	94		19
97	95		20
98	96		21
99	97		22
100	98		23
101	99		24
102	100
103	101		duties; modifying notice contents; defining terms;
104	102		updating statutory references; requiring certain time
105	103		period of tolling in certain declared disaster;
106	104		requiring certain documented proof by certain
107	105		pharmacy benefits managers; establishing certain
108	106		denial for certain appeals; prohibiting certain
109	107		collection of additional monies by certain pharmacy
110	108		benefits managers; establishing certain filing period
111	109		after lifting of disaster declaration; prohibiting
112	110		certain denials; updating statutory language;
113	111		providing for codification; and declaring an
114	112		emergency.
115	113
116	114
117	115
118	116
119	117		BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
120	118		SECTION 1. AMENDATORY 59 O.S. 2021, Section 356.1, as
121	119		amended by Section 1, Chapter 332, O.S.L. 2024 (59 O.S. Supp. 2024,
122	120		Section 356.1), is amended to read as follows:
123	121		Section 356.1. A. For purposes of the Pharmacy Audit Integrity
124	122		Act, “pharmacy benefits manager” :
125	123		1. “Audit” means any review, inspection, or analysis conducted
126	124		by a pharmacy benefits manager (PBM) or its representative of a
127	125		pharmacy’s records, practices, or compliance with contractual
128	126		obligations;
129	127		2. “Disaster declaration” and “declared disaster” mean a
130	128		declaration issued by the Governor or the President of the United
131	129		States for an event that qualifies as a disaster including, but not
132	130		limited to, a flood, tornado, earthquake, wildfire, terrorist
133	131		attack, or other catastrophic event; and
134	132
135		-	SB993 HFLR Page 3
136		-	BOLD FACE denotes Committee Amendments. 1
	133	+	Req. No. 13515 Page 3 1
137	134		2
138	135		3
139	136		4
140	137		5
141	138		6
142	139		7
143	140		8
144	141		9
145	142		10
146	143		11
147	144		12
148	145		13
149	146		14
150	147		15
151	148		16
152	149		17
153	150		18
154	151		19
155	152		20
156	153		21
157	154		22
158	155		23
159	156		24
160	157
161	158		3. “Pharmacy benefits manager” or “PBM” shall have the same
162	159		meaning as in Section 6960 of Title 36 of the Oklahoma Statutes.
163	160		B. The purpose of the Pharmacy Audit Integrity Act is to
164	161		establish minimum and uniform standards and criteria for the audit
165	162		of pharmacy records by or on behalf of certain entities.
166	163		C. The Pharmacy Audit In tegrity Act shall apply to any audit of
167	164		the records of a pharmacy conducted by a managed care company,
168	165		nonprofit hospital, medical service organization, insurance company,
169	166		third-party payor, pharmacy benefits manager, a health program
170	167		administered by a dep artment of this state, or any entity that
171	168		represents these companies, groups, or departments.
172	169		D. The Attorney General may promulgate rules to implement the
173	170		provisions of the Pharmacy Audit Integrity Act.
174	171		SECTION 2. AMENDATORY 59 O.S. 2021, Section 356.2, as
175	172		amended by Section 2, Chapter 332, O.S.L. 2024 (59 O.S. Supp. 2024,
176	173		Section 356.2), is amended to read as follows:
177	174		Section 356.2. A. The entity conducting an audit of a pharmacy
178	175		shall:
179	176		1. Identify and specifically describe t he audit and appeal
180	177		procedures in the pharmacy contract. Prescription claim
181	178		documentation and record-keeping recordkeeping requirements shall
182	179		not exceed the requirements set forth by the Oklahoma Pharmacy Act
183	180		or other applicable state or federal laws or r egulations;
184	181
185		-	SB993 HFLR Page 4
186		-	BOLD FACE denotes Committee Amendments. 1
	182	+	Req. No. 13515 Page 4 1
187	183		2
188	184		3
189	185		4
190	186		5
191	187		6
192	188		7
193	189		8
194	190		9
195	191		10
196	192		11
197	193		12
198	194		13
199	195		14
200	196		15
201	197		16
202	198		17
203	199		18
204	200		19
205	201		20
206	202		21
207	203		22
208	204		23
209	205		24
210	206
211	207		2. Give the pharmacy written notice by certified letter to the
212	208		pharmacy and the pharmacy’s contracting agent, including
213	209		identification of specific prescription numbers and, fill dates,
214	210		drug names, and National Drug Code (NDC) numbers to be audited, at
215	211		least fourteen (14) calendar days prior to conducting the audit,
216	212		including, but not limited to, an on -site audit, a desk audit, or a
217	213		wholesale purchase audit, request for documentation related to the
218	214		dispensing of a prescription drug , or any reimbursed activity by a
219	215		pharmacy provider; provided, however, that wholesale purchase audits
220	216		shall require a minimum of thirty (30) calendar days’ written
221	217		notice. For an on-site audit, the audit date shall be the date the
222	218		on-site audit occurs. For all other audit types, the audit date
223	219		shall be the date the pharmacy provides the documentation requested
224	220		in the audit notice. The pharmacy shall have the opportunity to
225	221		reschedule the audit no more than seven (7) calendar days from the
226	222		date designated on the origi nal audit notification;
227	223		3. Not interfere with the delivery of pharmacist services to a
228	224		patient and shall utilize every reasonable effort to minimize
229	225		inconvenience and disruption to pharmacy operations during the audit
230	226		process;
231	227		4. Conduct any audit involv ing clinical or professional
232	228		judgment by means of or in consultation with a licensed pharmacist;
233	229		5. Not consider as fraud any clerical or record-keeping
234	230		recordkeeping error, such as a typographical error, scrivener’s
235	231
236		-	SB993 HFLR Page 5
237		-	BOLD FACE denotes Committee Amendments. 1
	232	+	Req. No. 13515 Page 5 1
238	233		2
239	234		3
240	235		4
241	236		5
242	237		6
243	238		7
244	239		8
245	240		9
246	241		10
247	242		11
248	243		12
249	244		13
250	245		14
251	246		15
252	247		16
253	248		17
254	249		18
255	250		19
256	251		20
257	252		21
258	253		22
259	254		23
260	255		24
261	256
262	257		error or computer error, including, bu t not limited to, a
263	258		miscalculated day supply, incorrectly billed prescription written
264	259		date or prescription origin code, and such errors shall not be
265	260		subject to recoupment. The pharmacy shall have the right to submit
266	261		amended claims electronically to correc t clerical or record-keeping
267	262		recordkeeping errors in lieu of recoupment. To the extent that an
268	263		audit results in the identification of any clerical or record-
269	264		keeping recordkeeping errors such as typographical errors,
270	265		scrivener’s errors or computer errors i n a required document or
271	266		record, the pharmacy shall not be subject to recoupment of funds by
272	267		the pharmacy benefits manager unless the pharmacy benefits manager
273	268		can provide proof of intent to commit fraud. A person shall not be
274	269		subject to criminal penaltie s for errors provided for in this
275	270		paragraph without proof of intent to commit fraud;
276	271		6. Permit a pharmacy to use the records of a hospital,
277	272		physician, or other authorized practitioner of the healing arts for
278	273		drugs or medicinal supplies written or transmit ted by any means of
279	274		communication for purposes of validating the pharmacy record with
280	275		respect to orders or refills of a legend or narcotic drug;
281	276		7. Not include the dispensing fee amount or the actual invoice
282	277		cost of the prescription dispensed in a finding of an audit
283	278		recoupment unless a prescription was not actually dispensed or a
284	279		physician denied authorization of a dispensing order;
285	280
286		-	SB993 HFLR Page 6
287		-	BOLD FACE denotes Committee Amendments. 1
	281	+	Req. No. 13515 Page 6 1
288	282		2
289	283		3
290	284		4
291	285		5
292	286		6
293	287		7
294	288		8
295	289		9
296	290		10
297	291		11
298	292		12
299	293		13
300	294		14
301	295		15
302	296		16
303	297		17
304	298		18
305	299		19
306	300		20
307	301		21
308	302		22
309	303		23
310	304		24
311	305
312	306		8. Audit each pharmacy under identical standards, regularity
313	307		and parameters as other similarly situated pharmacies and all
314	308		pharmacies owned or managed by the pharmacy benefits manager
315	309		conducting or having conducted the audit;
316	310		9. Not exceed one (1) year from the date the claim was
317	311		submitted to or adjudicated by a managed care company, nonprofit
318	312		hospital or medical service orga nization, insurance company, third-
319	313		party payor, pharmacy benefits manager, a health program
320	314		administered by a department of this state, or any entity that
321	315		represents the companies, groups, or departments for the period
322	316		covered by an audit;
323	317		10. Not schedule or initiate an audit during the first seven
324	318		(7) calendar days of any month unless otherwise consented to by the
325	319		pharmacy;
326	320		11. Disclose to any plan sponsor whose claims were included in
327	321		the audit any money recouped in the audit;
328	322		12. Not require pharmaci sts to break open packaging labeled
329	323		“for single-patient-use only”. Packaging labeled “for single -
330	324		patient-use only” shall be deemed to be the smallest package size
331	325		available; and
332	326		13. Upon recoupment of funds from a pharmacy, refund first to
333	327		the patient the portion of the recovered funds that were originally
334	328		paid by the patient, provided such funds were part of the
335	329		recoupment; and
336	330
337		-	SB993 HFLR Page 7
338		-	BOLD FACE denotes Committee Amendments. 1
	331	+	Req. No. 13515 Page 7 1
339	332		2
340	333		3
341	334		4
342	335		5
343	336		6
344	337		7
345	338		8
346	339		9
347	340		10
348	341		11
349	342		12
350	343		13
351	344		14
352	345		15
353	346		16
354	347		17
355	348		18
356	349		19
357	350		20
358	351		21
359	352		22
360	353		23
361	354		24
362	355
363	356		14. Not assess a fine, penalty, or any other financial
364	357		requirement on the pharmacy or pharmacist for any prescription
365	358		audited unless there is a valid recoupment under the Pharmacy Audit
366	359		Integrity Act.
367	360		B. 1. Any entity that conducts wholesale purchase review
368	361		during an audit of a pharmacist or pharmacy shall not require the
369	362		pharmacist or pharmacy to provide a full dispensing repor t.
370	363		Wholesaler invoice reviews shall be limited to verification of
371	364		purchase inventory specific to the pharmacy claims paid by the
372	365		health benefits plan or pharmacy benefits manager conducting the
373	366		audit.
374	367		2. Any entity conducting an audit shall not identify or label a
375	368		prescription claim as an audit discrepancy when:
376	369		a. the National Drug Code for the dispensed drug is in a
377	370		quantity that is a subunit or multiple of the drug
378	371		purchased by the pharmacist or pharmacy as supported
379	372		by a wholesale invoice,
380	373		b. the pharmacist or pharmacy dispensed the correct
381	374		quantity of the drug according to the prescription,
382	375		and
383	376		c. the drug dispensed by the pharmacist or pharmacy
384	377		shares all but the last two digits of the National
385	378		Drug Code of the drug reflected on the supplier
386	379		invoice.
387	380
388		-	SB993 HFLR Page 8
389		-	BOLD FACE denotes Committee Amendments. 1
	381	+	Req. No. 13515 Page 8 1
390	382		2
391	383		3
392	384		4
393	385		5
394	386		6
395	387		7
396	388		8
397	389		9
398	390		10
399	391		11
400	392		12
401	393		13
402	394		14
403	395		15
404	396		16
405	397		17
406	398		18
407	399		19
408	400		20
409	401		21
410	402		22
411	403		23
412	404		24
413	405
414	406		3. An entity conducting an audit shall accept as evidence,
415	407		subject to validation, to support the validity of a pharmacy claim
416	408		related to a dispensed drug:
417	409		a. redacted copies of supplier invoices in the
418	410		pharmacist’s or pharmacy’s possession, or
419	411		b. invoices and any supporting documents from any
420	412		supplier as authorized by federal or state law to
421	413		transfer ownership of the drug acquired by the
422	414		pharmacist or pharmacy.
423	415		4. An entity conducting an audit shall provide, no later than
424	416		five (5) calendar days after the date of a request by the pharmacist
425	417		or pharmacy, all supporting documents the pharmacist’s or pharmacy’s
426	418		purchase suppliers provided to the health benefits plan issuer or
427	419		pharmacy benefits manager.
428	420		C. A pharmacy shall be allowed to provide the pharmacy’s
429	421		computerized patterned medical records or the records of a hospital,
430	422		physician, or other authorized practitioner of the healing arts for
431	423		drugs or medicinal supplies written or transmitted by any means of
432	424		communication for purposes of supporting the pharma cy record with
433	425		respect to orders or refills of a legend or narcotic drug.
434	426		D. The entity conducting the audit shall not audit more than
435	427		fifty prescriptions, with specific date of service, per calendar
436	428		year PBM or its agent shall not exceed an annual limit of fifty
437	429		prescription claims with a specific prescription number and date of
438	430
439		-	SB993 HFLR Page 9
440		-	BOLD FACE denotes Committee Amendments. 1
	431	+	Req. No. 13515 Page 9 1
441	432		2
442	433		3
443	434		4
444	435		5
445	436		6
446	437		7
447	438		8
448	439		9
449	440		10
450	441		11
451	442		12
452	443		13
453	444		14
454	445		15
455	446		16
456	447		17
457	448		18
458	449		19
459	450		20
460	451		21
461	452		22
462	453		23
463	454		24
464	455
465	456		fill per calendar year . The annual limit to the number of
466	457		prescription claims audited shall be inclusive of all audits by a
467	458		PBM or its agent, including any prescription -related documentation
468	459		requests from the health insurer, pharmacy benefits manager or any
469	460		third-party company conducting audits on behalf of any health
470	461		insurer or pharmacy benefits manager during a calendar year.
471	462		E. If paper copies of records are requested by the e ntity
472	463		conducting the audit, the entity shall pay twenty -five cents ($0.25)
473	464		per page to cover the costs incurred by the pharmacy. The entity
474	465		conducting the audit shall provide the pharmacy with accurate
475	466		instructions, including any required form for obtaini ng
476	467		reimbursement for the copied records.
477	468		F. The entity conducting the audit shall:
478	469		1. Deliver a preliminary audit findings report to the pharmacy
479	470		and the pharmacy’s contracting agent within forty -five (45) calendar
480	471		days of conducting the audit;
481	472		2. Allow the pharmacy at least ninety (90) calendar days
482	473		following receipt of the preliminary audit findings report in which
483	474		to produce documentation to address any discrepancy found during the
484	475		audit; provided, however, a pharmacy may request an extension, not
485	476		to exceed an additional forty-five (45) calendar days;
486	477		3. Deliver a final audit findings report to the pharmacy and
487	478		the pharmacy’s contracting agent signed by the auditor within ten
488	479		(10) calendar days after receipt of additional documentation
489	480
490		-	SB993 HFLR Page 10
491		-	BOLD FACE denotes Committee Amendments. 1
	481	+	Req. No. 13515 Page 10 1
492	482		2
493	483		3
494	484		4
495	485		5
496	486		6
497	487		7
498	488		8
499	489		9
500	490		10
501	491		11
502	492		12
503	493		13
504	494		14
505	495		15
506	496		16
507	497		17
508	498		18
509	499		19
510	500		20
511	501		21
512	502		22
513	503		23
514	504		24
515	505
516	506		provided by the pharmacy, as provided for in Section 356.3 of this
517	507		title;
518	508		4. Allow the pharmacy to reverse and resubmit claims
519	509		electronically within thirty (30) calendar days of receipt of the
520	510		final audit report in lieu of the auditing entity recouping
521	511		discrepant claim amounts from the pharmacy;
522	512		5. Not recoup any disputed funds until after final disposition
523	513		of the audit findings, including the appeals process as provided for
524	514		in Section 356.3 of this title; and
525	515		6. Not accrue interest during the audit and appeal period ;
526	516		7. Ensure that each preliminary audit findings report required
527	517		by this section includes:
528	518		a. specific prescription numbers, fill dates, drug names,
529	519		and NDC numbers, and
530	520		b. the date of receipt of documents from the pharmacy,
531	521		the pharmacy’s contracting agent , or any other source
532	522		associated with the audit .
533	523		G. Each entity conducting an audit shall provide a copy of the
534	524		final audit results, and a final audit report upon request, after
535	525		completion of any review process to the plan sponsor
536	526		In addition to the requi rements for a preliminary audit findings
537	527		report in this paragraph, the final audit findings report shall
538	528		include any additional documentation that was submitted to the
539	529		auditing entity;
540	530
541		-	SB993 HFLR Page 11
542		-	BOLD FACE denotes Committee Amendments. 1
	531	+	Req. No. 13515 Page 11 1
543	532		2
544	533		3
545	534		4
546	535		5
547	536		6
548	537		7
549	538		8
550	539		9
551	540		10
552	541		11
553	542		12
554	543		13
555	544		14
556	545		15
557	546		16
558	547		17
559	548		18
560	549		19
561	550		20
562	551		21
563	552		22
564	553		23
565	554		24
566	555
567	556		8. Provide the plan sponsor a copy of the final audit results
568	557		within thirty (30) calendar days of the final disposition of the
569	558		audit; and
570	559		9. At the request of the plan sponsor, provide a copy of the
571	560		final audit findings report within thirty (30) calendar days of the
572	561		request.
573	562		H. G. 1. The full amount of any recoupment on a n audit shall
574	563		be refunded to the plan sponsor. Except as provided for in
575	564		paragraph 2 of this subsection, a charge or assessment for an audit
576	565		shall not be based, directly or indirectly, on amounts recouped.
577	566		2. This subsection does not prevent the entity c onducting the
578	567		audit from charging or assessing the responsible party, directly or
579	568		indirectly, based on amounts recouped if both of the following
580	569		conditions are met:
581	570		a. the plan sponsor and the entity conducting the audit
582	571		have a contract that explicitly sta tes the percentage
583	572		charge or assessment to the plan sponsor, and
584	573		b. a commission to an agent or employee of the entity
585	574		conducting the audit is not based, directly or
586	575		indirectly, on amounts recouped.
587	576		I. H. Unless superseded by state or federal law, auditor s shall
588	577		only have access to previous audit reports on a particular pharmacy
589	578		conducted by the auditing entity for the same pharmacy benefits
590	579		manager, health plan or insurer. An auditing vendor contracting
591	580
592		-	SB993 HFLR Page 12
593		-	BOLD FACE denotes Committee Amendments. 1
	581	+	Req. No. 13515 Page 12 1
594	582		2
595	583		3
596	584		4
597	585		5
598	586		6
599	587		7
600	588		8
601	589		9
602	590		10
603	591		11
604	592		12
605	593		13
606	594		14
607	595		15
608	596		16
609	597		17
610	598		18
611	599		19
612	600		20
613	601		21
614	602		22
615	603		23
616	604		24
617	605
618	606		with multiple pharmacy benefits managers or health insurance plans
619	607		shall not use audit reports or other information gained from an
620	608		audit on a pharmacy to conduct another audit for a different
621	609		pharmacy benefits manager or health insurance plan.
622	610		J. Sections A through I
623	611		I. Paragraph 2 of subsection A of thi s section through
624	612		subsection D of this section, and paragraph 1 through paragraph 7 of
625	613		subsection F of this section shall not apply to any audit initiated
626	614		based on or that involves suspicion of fraud, willful
627	615		misrepresentation, or abuse.
628	616		K. J. If the Attorney General, after notice and opportunity for
629	617		hearing, finds that the entity conducting the audit failed to follow
630	618		any of the requirements pursuant to the Pharmacy Audit Integrity
631	619		Act, the audit shall be considered null and void. Any monies
632	620		recouped from a null and void audit shall be returned to the
633	621		affected pharmacy within fourteen (14) calendar days. Any violation
634	622		of this section by a pharmacy benefits manager or auditing entity
635	623		shall be deemed a violation of the Pharmacy Audit Integrity Act.
636	624		SECTION 3. AMENDATORY 59 O.S. 2021, Section 356.3, as
637	625		amended by Section 3, Chapter 332, O.S.L. 2024 (59 O.S. Supp. 2024,
638	626		Section 356.3), is amended to read as follows:
639	627		Section 356.3. A. Each entity conducting an audit shall
640	628		establish a written appeals process under which a pharmacy may
641	629
642		-	SB993 HFLR Page 13
643		-	BOLD FACE denotes Committee Amendments. 1
	630	+	Req. No. 13515 Page 13 1
644	631		2
645	632		3
646	633		4
647	634		5
648	635		6
649	636		7
650	637		8
651	638		9
652	639		10
653	640		11
654	641		12
655	642		13
656	643		14
657	644		15
658	645		16
659	646		17
660	647		18
661	648		19
662	649		20
663	650		21
664	651		22
665	652		23
666	653		24
667	654
668	655		appeal an unfavorable preliminary audit report and/or final audit
669	656		report to the entity.
670	657		B. Following an appeal, if the entity finds that an unfavorable
671	658		audit report or any portion thereof is unsubstantia ted, the entity
672	659		shall dismiss the audit report or the unsubstantiated portion of the
673	660		audit report without any further action.
674	661		C. Any final audit report, following the final audit appeal
675	662		period, with a finding of fraud or willful misrepresentation shall
676	663		be referred to the district attorney having proper jurisdiction or
677	664		the Attorney General for prosecution upon completion of the appeals
678	665		process. If a finding of fraud or willful misrepresentation is
679	666		referred to a district attorney under this subsection, the auditing
680	667		entity shall notify the Attorney General as to whom the referral was
681	668		made and the date the referral was made.
682	669		D. For any audit initiated based on or that involves suspicion
683	670		of fraud, willful misrepresentation, or abuse, the auditing entity
684	671		shall provide, in writing, at the time of the audit, a clear and
685	672		conspicuous declaration to the pharmacy being audited that the audit
686	673		is being conducted under suspicion of fraud, willful
687	674		misrepresentation, or abuse and a statement of facts that supports
688	675		the reasonable suspicion. The entity conducting an audit based on
689	676		suspicion of fraud, willful misrepresentation, or abuse shall
690	677		provide a copy of the clear and conspicuous declaration required by
691	678		this subsection to the pharmacy’s contracting agent by certified
692	679
693		-	SB993 HFLR Page 14
694		-	BOLD FACE denotes Committee Amendments. 1
	680	+	Req. No. 13515 Page 14 1
695	681		2
696	682		3
697	683		4
698	684		5
699	685		6
700	686		7
701	687		8
702	688		9
703	689		10
704	690		11
705	691		12
706	692		13
707	693		14
708	694		15
709	695		16
710	696		17
711	697		18
712	698		19
713	699		20
714	700		21
715	701		22
716	702		23
717	703		24
718	704
719	705		mail within five (5) business days of notifying the pharmacy of an
720	706		audit pursuant to this section.
721	707		E. The entity conducting an audit based on suspicion of fraud,
722	708		willful misrepresentation, or abuse shall:
723	709		1. Deliver a preliminary findings report to the pha rmacy and
724	710		the pharmacy’s contracting agent within ninety (90) calendar days of
725	711		notification of the audit;
726	712		2. Allow the pharmacy at least ninety (90) calendar days
727	713		following the receipt of the preliminary audit findings report in
728	714		which to produce documenta tion to address any discrepancy found
729	715		during the audit. A pharmacy may request an extension, not to
730	716		exceed an additional forty -five (45) calendar days;
731	717		3. Deliver a final audit findings report to the pharmacy and
732	718		the pharmacy’s contracting agent signed b y the auditor within thirty
733	719		(30) calendar days after receipt of additional documentation
734	720		provided by the pharmacy;
735	721		4. Allow the pharmacy to reverse and resubmit claims
736	722		electronically within thirty (30) calendar days of receipt of the
737	723		final audit report in lieu of the auditing entity recouping
738	724		discrepant claim amounts from the pharmacy;
739	725		5. Not recoup any disputed funds until after the final
740	726		disposition of the audit findings, including the appeals process
741	727		pursuant to this section;
742	728		6. Not accrue interest du ring the audit and appeal period;
743	729
744		-	SB993 HFLR Page 15
745		-	BOLD FACE denotes Committee Amendments. 1
	730	+	Req. No. 13515 Page 15 1
746	731		2
747	732		3
748	733		4
749	734		5
750	735		6
751	736		7
752	737		8
753	738		9
754	739		10
755	740		11
756	741		12
757	742		13
758	743		14
759	744		15
760	745		16
761	746		17
762	747		18
763	748		19
764	749		20
765	750		21
766	751		22
767	752		23
768	753		24
769	754
770	755		7. Ensure that each preliminary audit findings report submitted
771	756		pursuant to this section includes:
772	757		a. specific prescription numbers, fill dates, drug names,
773	758		and NDC numbers, and
774	759		b. the date of receipt of documents from th e pharmacy,
775	760		the pharmacy’s contracting agent, or any other source
776	761		associated with the audit;
777	762		8. Ensure that each final audit findings report includes any
778	763		additional documentation that was submitted to the auditing entity;
779	764		9. Provide the plan sponsor a co py of the final audit results
780	765		within thirty (30) calendar days of the final disposition of the
781	766		audit; and
782	767		10. At the request of the plan sponsor, provide a copy of the
783	768		final audit report within thirty (30) calendar days of the request.
784	769		F. Any entity conducting an audit that is based on or involves
785	770		suspicion of fraud, willful misrepresentation, or abuse shall
786	771		provide to the Office of the Attorney General:
787	772		1. Notice at least two (2) calendar days prior to beginning
788	773		performance of an audit pursuant to this section;
789	774		2. A preliminary report within thirty (30) calendar days of
790	775		performing the audit five (5) business days of providing a copy of
791	776		the preliminary report to the pharmacy and the pharmacy’s
792	777		contracting agent pursuant to this section . The auditing entity may
793	778
794		-	SB993 HFLR Page 16
795		-	BOLD FACE denotes Committee Amendments. 1
	779	+	Req. No. 13515 Page 16 1
796	780		2
797	781		3
798	782		4
799	783		5
800	784		6
801	785		7
802	786		8
803	787		9
804	788		10
805	789		11
806	790		12
807	791		13
808	792		14
809	793		15
810	794		16
811	795		17
812	796		18
813	797		19
814	798		20
815	799		21
816	800		22
817	801		23
818	802		24
819	803
820	804		request an extension from the Attorney General, not to exceed an
821	805		additional ninety (90) calendar days ; and
822	806		3. A final report within thirty (30) ten (10) calendar days
823	807		following the closure of the final appeal period for an audit
824	808		performed pursuant to this section.
825	809		a. The final report for the Office of the Attorney
826	810		General shall include the name of each plan sponsor
827	811		whose claims were included in the audit recover, the
828	812		amount of funds recouped on behalf of the plan, the
829	813		date the plan sponsor was noti fied of the recoupment,
830	814		the date the plan sponsor was paid any recoupment, and
831	815		the name and contact information for the
832	816		representative of the plan sponsor who was notified of
833	817		the recoupment at issue in an audit pursuant to this
834	818		section.
835	819		b. The auditing entity may request an extension from the
836	820		Attorney General, not to exceed an additional ten (10)
837	821		calendar days.
838	822		F. G. The Attorney General, authorized employees, and examiners
839	823		shall have access to any pharmacy benefits manager’s files and
840	824		records that may rel ate to an any audit including, but not limited
841	825		to, an audit that is based on or involves suspicion of fraud,
842	826		willful misrepresentation, or abuse.
843	827
844		-	SB993 HFLR Page 17
845		-	BOLD FACE denotes Committee Amendments. 1
	828	+	Req. No. 13515 Page 17 1
846	829		2
847	830		3
848	831		4
849	832		5
850	833		6
851	834		7
852	835		8
853	836		9
854	837		10
855	838		11
856	839		12
857	840		13
858	841		14
859	842		15
860	843		16
861	844		17
862	845		18
863	846		19
864	847		20
865	848		21
866	849		22
867	850		23
868	851		24
869	852
870	853		G. H. The Attorney General may levy a civil or administrative
871	854		fine of not less than One Hundred Dollars ($100 .00) and not greater
872	855		than Ten Thousand Dollars ($10,000.00) for each violation of this
873	856		section and assess any other penalty or remedy authorized by law.
874	857		SECTION 4. AMENDATORY 59 O.S. 2021, Section 356.4, is
875	858		amended to read as foll ows:
876	859		Section 356.4. A. For the purposes of the Pharmacy Audit
877	860		Integrity Act, “extrapolation audit” means an audit of a sample of
878	861		prescription drug benefit claims submitted by a pharmacy to the
879	862		entity conducting the audit that is then used to estimate aud it
880	863		results for a larger batch or group of claims not reviewed by the
881	864		auditor, including refills not listed in the written notification in
882	865		accordance with paragraph 2 of subsection A of Section 356.2 of this
883	866		title.
884	867		B. The entity conducting the audit shall not use the accounting
885	868		practice of extrapolation in calculating recoupments or penalties
886	869		for audits.
887	870		SECTION 5. NEW LAW A new section of law to be codified
888	871		in the Oklahoma Statutes as Section 356.6 of Title 59, unless there
889	872		is created a duplication in numbering, reads as follows:
890	873		A. Notwithstanding any other provision of law, the ability of a
891	874		pharmacy benefits manager (PBM) to initiate, continue, or conclude
892	875		an audit of a pharmacy shall be tolled for the duration of a
893	876
894		-	SB993 HFLR Page 18
895		-	BOLD FACE denotes Committee Amendments. 1
	877	+	Req. No. 13515 Page 18 1
896	878		2
897	879		3
898	880		4
899	881		5
900	882		6
901	883		7
902	884		8
903	885		9
904	886		10
905	887		11
906	888		12
907	889		13
908	890		14
909	891		15
910	892		16
911	893		17
912	894		18
913	895		19
914	896		20
915	897		21
916	898		22
917	899		23
918	900		24
919	901
920	902		declared disaster and for an additional period of thirty (30)
921	903		calendar days following the termination of a declared disaster.
922	904		Such requirement shall apply only to the pharmacies located
923	905		within the geographical boundaries of the county or counties
924	906		affected by the declare d disaster.
925	907		B. The provisions of this section shall apply to all PBMs
926	908		operating within this state, and to all audits conducted pursuant to
927	909		contracts between PBMs and pharmacies.
928	910		C. This section shall not apply to:
929	911		1. Audits conducted for suspected fraud ulent activity if
930	912		documented evidence of such activity exists; or
931	913		2. Audits required to comply with federal or state law
932	914		unrelated to the contractual relationship between a PBM and a
933	915		pharmacy.
934	916		D. Nothing in this section shall be construed to prohibit a
935	917		pharmacy from voluntarily agreeing to continue or complete an audit
936	918		during the tolling period, provided such agreement is documented in
937	919		writing and signed by both parties.
938	920		E. A PBM may submit a request to the Attorney General to
939	921		continue or complete an aud it during the tolling period, which the
940	922		Attorney General may grant at his or her sole discretion. Any PBM
941	923		granted such permission by the Attorney General shall do so pursuant
942	924		to the requirements of this act.
943	925
944		-	SB993 HFLR Page 19
945		-	BOLD FACE denotes Committee Amendments. 1
	926	+	Req. No. 13515 Page 19 1
946	927		2
947	928		3
948	929		4
949	930		5
950	931		6
951	932		7
952	933		8
953	934		9
954	935		10
955	936		11
956	937		12
957	938		13
958	939		14
959	940		15
960	941		16
961	942		17
962	943		18
963	944		19
964	945		20
965	946		21
966	947		22
967	948		23
968	949		24
969	950
970	951		SECTION 6. AMENDATORY 59 O.S. 2021, Section 357, as
971	952		amended by Section 4, Chapter 332, O.S.L. 2024 (59 O.S. Supp. 2024,
972	953		Section 357), is amended to read as follows:
973	954		Section 357. A. As used in Sections 357 through 360 of this
974	955		title and Section 9 of this act:
975	956		1. “Covered entity” means a nonprofit hospital or medical
976	957		service organization, for -profit hospital or medical service
977	958		organization, insurer, health benefit plan, health maintenance
978	959		organization, health program administered by the state in the
979	960		capacity of providing health coverage, or an employer, labor union,
980	961		or other group of persons that provides health coverage to persons
981	962		in this state. This term does not include a health benefit plan
982	963		that provides coverage only for accidental injury, specified
983	964		disease, hospital indem nity, disability income, or other limited
984	965		benefit health insurance policies and contracts that do not include
985	966		prescription drug coverage;
986	967		2. “Covered individual” means a member, participant, enrollee,
987	968		contract holder or policy holder or beneficiary of a c overed entity
988	969		who is provided health coverage by the covered entity. A covered
989	970		individual includes any dependent or other person provided health
990	971		coverage through a policy, contract or plan for a covered
991	972		individual;
992	973		3. “Department” means the Insurance Dep artment;
993	974
994		-	SB993 HFLR Page 20
995		-	BOLD FACE denotes Committee Amendments. 1
	975	+	Req. No. 13515 Page 20 1
996	976		2
997	977		3
998	978		4
999	979		5
1000	980		6
1001	981		7
1002	982		8
1003	983		9
1004	984		10
1005	985		11
1006	986		12
1007	987		13
1008	988		14
1009	989		15
1010	990		16
1011	991		17
1012	992		18
1013	993		19
1014	994		20
1015	995		21
1016	996		22
1017	997		23
1018	998		24
1019	999
1020	1000		4. “Maximum allowable cost”, “MAC”, or “MAC list” means the
1021	1001		list of drug products delineating the maximum per -unit reimbursement
1022	1002		for multiple-source prescription drugs, medical product, or device;
1023	1003		5. “Multisource drug product reimbursement” (rei mbursement)
1024	1004		means the total amount paid to a pharmacy inclusive of any reduction
1025	1005		in payment to the pharmacy, excluding prescription dispense fees;
1026	1006		6. “Office” means the Office of the Attorney General;
1027	1007		7. “Pharmacy benefits management” means a service pro vided to
1028	1008		covered entities to facilitate the provision of prescription drug
1029	1009		benefits to covered individuals within the state, including
1030	1010		negotiating pricing and other terms with drug manufacturers and
1031	1011		providers. Pharmacy benefits management may include any or all of
1032	1012		the following services:
1033	1013		a. claims processing, retail network management and
1034	1014		payment of claims to pharmacies for prescription drugs
1035	1015		dispensed to covered individuals,
1036	1016		b. clinical formulary development and management
1037	1017		services, or
1038	1018		c. rebate contracting and administration;
1039	1019		8. “Pharmacy benefits manager” or “PBM” means a person,
1040	1020		business, or other entity that performs pharmacy benefits
1041	1021		management. The term shall include any business or entity licensed
1042	1022		by the Insurance Department to perform PBM service s, or a person or
1043	1023		entity acting on behalf of a PBM in a contractual or employment
1044	1024
1045		-	SB993 HFLR Page 21
1046		-	BOLD FACE denotes Committee Amendments. 1
	1025	+	Req. No. 13515 Page 21 1
1047	1026		2
1048	1027		3
1049	1028		4
1050	1029		5
1051	1030		6
1052	1031		7
1053	1032		8
1054	1033		9
1055	1034		10
1056	1035		11
1057	1036		12
1058	1037		13
1059	1038		14
1060	1039		15
1061	1040		16
1062	1041		17
1063	1042		18
1064	1043		19
1065	1044		20
1066	1045		21
1067	1046		22
1068	1047		23
1069	1048		24
1070	1049
1071	1050		relationship in the performance of pharmacy benefits management for
1072	1051		a managed care company, nonprofit hospital, medical service
1073	1052		organization, insurance company, third -party payor, or a health
1074	1053		program administered by an agency or department of this state;
1075	1054		9. “Plan sponsor” means the employers, insurance companies,
1076	1055		unions and health maintenance organizations or any other entity
1077	1056		responsible for establishing, maintaining, or admi nistering a health
1078	1057		benefit plan on behalf of covered individuals; and
1079	1058		10. “Provider” means a pharmacy licensed by the State Board of
1080	1059		Pharmacy, or an agent or representative of a pharmacy, including,
1081	1060		but not limited to, the pharmacy’s contracting agent, wh ich
1082	1061		dispenses prescription drugs or devices to covered individuals.
1083	1062		B. Nothing in the definition of pharmacy benefits management or
1084	1063		pharmacy benefits manager in the Patient’s Right to Pharmacy Choice
1085	1064		Act, Pharmacy Audit Integrity Act, or Sections 357 through 360 of
1086	1065		this title, or Section 9 of this act shall deem an employer a
1087	1066		“pharmacy benefits manager” pharmacy benefits manager of its own
1088	1067		self-funded health benefit plan, except, to the extent permitted by
1089	1068		applicable law, where the employer, without the ut ilization of a
1090	1069		third party and unrelated to the employer’s own pharmacy:
1091	1070		a. negotiates
1092	1071		1. Negotiates directly with drug manufacturers ,;
1093	1072		b. processes
1094	1073		2. Processes claims on behalf of its members ,; or
1095	1074
1096		-	SB993 HFLR Page 22
1097		-	BOLD FACE denotes Committee Amendments. 1
	1075	+	Req. No. 13515 Page 22 1
1098	1076		2
1099	1077		3
1100	1078		4
1101	1079		5
1102	1080		6
1103	1081		7
1104	1082		8
1105	1083		9
1106	1084		10
1107	1085		11
1108	1086		12
1109	1087		13
1110	1088		14
1111	1089		15
1112	1090		16
1113	1091		17
1114	1092		18
1115	1093		19
1116	1094		20
1117	1095		21
1118	1096		22
1119	1097		23
1120	1098		24
1121	1099
1122	1100		c. manages
1123	1101		3. Manages its own retail network of pharma cies.
1124	1102		SECTION 7. AMENDATORY 59 O.S. 2021, Section 358, as
1125	1103		amended by Section 5, Chapter 332, O.S.L. 2024 (59 O.S. Supp. 2024,
1126	1104		Section 358), is amended to read as follows:
1127	1105		Section 358. A. In order to provide pharmacy benefits
1128	1106		management or any of the services included under the definition of
1129	1107		pharmacy benefits management in this state, a pharmacy benefits
1130	1108		manager or any entity acting as one in a contractual or employment
1131	1109		relationship for a covered entity shall first obtain a licens e from
1132	1110		the Insurance Department, and the Department may charge a fee for
1133	1111		such licensure.
1134	1112		B. The Department shall establish, by regulation, licensure
1135	1113		procedures, required disclosures for pharmacy benefits managers
1136	1114		(PBMs) and other rules as may be necessary for carrying out and
1137	1115		enforcing the provisions of this title. The licensure procedures
1138	1116		shall, at a minimum, include the completion of an application form
1139	1117		that shall include the name and address of an agent for service of
1140	1118		process, the payment of a requisit e fee, and evidence of the
1141	1119		procurement of a surety bond.
1142	1120		C. The Department or the Office of the Attorney General may
1143	1121		subpoena witnesses and information. Its compliance officers may
1144	1122		take and copy records for investigative use and prosecutions.
1145	1123		Nothing in this subsection shall limit the Office of the Attorney
1146	1124
1147		-	SB993 HFLR Page 23
1148		-	BOLD FACE denotes Committee Amendments. 1
	1125	+	Req. No. 13515 Page 23 1
1149	1126		2
1150	1127		3
1151	1128		4
1152	1129		5
1153	1130		6
1154	1131		7
1155	1132		8
1156	1133		9
1157	1134		10
1158	1135		11
1159	1136		12
1160	1137		13
1161	1138		14
1162	1139		15
1163	1140		16
1164	1141		17
1165	1142		18
1166	1143		19
1167	1144		20
1168	1145		21
1169	1146		22
1170	1147		23
1171	1148		24
1172	1149
1173	1150		General from using its investigative demand authority to investigate
1174	1151		and prosecute violations of the law.
1175	1152		D. The Department may suspend, revoke or refuse to issue or
1176	1153		renew a license for noncompliance with any of the provisions hereby
1177	1154		established or with the rules promulgated by the Department; for
1178	1155		conduct likely to mislead, deceive or defraud the public or the
1179	1156		Department; for unfair or deceptive business practices or for
1180	1157		nonpayment of an application o r renewal fee or fine. The Department
1181	1158		may also levy administrative fines for each count of which a PBM has
1182	1159		been convicted in a Department hearing.
1183	1160		E. 1. The Office of the Attorney General , after notice and
1184	1161		opportunity for hearing, may instruct the Insur ance Commissioner
1185	1162		that the PBM’s license be censured, suspended, or revoked for
1186	1163		conduct likely to mislead, deceive, or defraud the public or the
1187	1164		State of Oklahoma; or for unfair or deceptive business practices, or
1188	1165		for any violation of the Patient’s Right t o Pharmacy Choice Act, the
1189	1166		Pharmacy Audit Integrity Act, or Sections 357 through 360 of this
1190	1167		title, or Section 9 of this act. The Office of the Attorney General
1191	1168		may also levy administrative fines for each count of which a PBM has
1192	1169		been convicted following a hearing before the Attorney General. If
1193	1170		the Attorney General makes such instruction, the Commissioner shall
1194	1171		enforce the instructed action within thirty (30) calendar days.
1195	1172		2. In addition to or in lieu of any censure, suspension, or
1196	1173		revocation of a lice nse by the Commissioner, the Attorney General
1197	1174
1198		-	SB993 HFLR Page 24
1199		-	BOLD FACE denotes Committee Amendments. 1
	1175	+	Req. No. 13515 Page 24 1
1200	1176		2
1201	1177		3
1202	1178		4
1203	1179		5
1204	1180		6
1205	1181		7
1206	1182		8
1207	1183		9
1208	1184		10
1209	1185		11
1210	1186		12
1211	1187		13
1212	1188		14
1213	1189		15
1214	1190		16
1215	1191		17
1216	1192		18
1217	1193		19
1218	1194		20
1219	1195		21
1220	1196		22
1221	1197		23
1222	1198		24
1223	1199
1224	1200		may levy a civil or administrative fine of not less than One Hundred
1225	1201		Dollars ($100.00) and not greater than Ten Thousand Dollars
1226	1202		($10,000.00) for each violation of this subsection and/or assess any
1227	1203		other penalty or remedy authorized by this section. For purposes of
1228	1204		this section, each day a PBM fails to comply with an investigation
1229	1205		or inquiry may be considered a separate violation.
1230	1206		F. The Attorney General may promulgate rules to implement the
1231	1207		provisions of Sections 357 through 360 of this title and Section 9
1232	1208		of this act.
1233	1209		SECTION 8. AMENDATORY 59 O.S. 2021, Section 360, as
1234	1210		amended by Section 6, Chapter 332, O.S.L. 2024 (59 O.S. Supp. 2024,
1235	1211		Section 360), is amended to read as follows:
1236	1212		Section 360. A. The pharmacy benefits manager shall, with
1237	1213		respect to contracts between a pharmacy benefits manager and a
1238	1214		provider, including a pharmacy service administrative organization:
1239	1215		l. Include in such contracts the specific sources utilized to
1240	1216		determine the maximum allowable cost (MAC) pricing of the pharmacy,
1241	1217		update MAC pricing at least every seven (7) calendar days, and
1242	1218		establish a process for providers to readily access the MAC list
1243	1219		specific to that provider;
1244	1220		2. In order to place a drug on the MA C list, ensure that the
1245	1221		drug is listed as “A” or “B” rated in the most recent version of the
1246	1222		FDA’s United States Food and Drug Administration (FDA) Approved Drug
1247	1223		Products with Therapeutic Equivalence Evaluations, also known as the
1248	1224
1249		-	SB993 HFLR Page 25
1250		-	BOLD FACE denotes Committee Amendments. 1
	1225	+	Req. No. 13515 Page 25 1
1251	1226		2
1252	1227		3
1253	1228		4
1254	1229		5
1255	1230		6
1256	1231		7
1257	1232		8
1258	1233		9
1259	1234		10
1260	1235		11
1261	1236		12
1262	1237		13
1263	1238		14
1264	1239		15
1265	1240		16
1266	1241		17
1267	1242		18
1268	1243		19
1269	1244		20
1270	1245		21
1271	1246		22
1272	1247		23
1273	1248		24
1274	1249
1275	1250		Orange Book, and the drug is generally available for purchase by
1276	1251		pharmacies in the state from national or regional wholesalers and is
1277	1252		not obsolete;
1278	1253		3. Ensure dispensing fees are not included in the calculation
1279	1254		of MAC price reimbursement to pharmacy providers;
1280	1255		4. Provide a reason able administration appeals procedure to
1281	1256		allow a provider, a provider’s representative and a pharmacy service
1282	1257		administrative organization to contest reimbursement amounts within
1283	1258		fourteen (14) calendar days of the final adjusted payment date. The
1284	1259		pharmacy benefits manager shall not prevent the pharmacy or the
1285	1260		pharmacy service administrative organization from filing
1286	1261		reimbursement appeals in an electronic batch format. The pharmacy
1287	1262		benefits manager must respond to a provider, a provider’s
1288	1263		representative and a pharmacy service administrative organization
1289	1264		who have contested a reimbursement amount through this procedure
1290	1265		within ten (10) calendar days. The pharmacy benefits manager must
1291	1266		respond in an electronic batch format to reimbursement appeals filed
1292	1267		in an electronic batch format. The pharmacy benefits manager shall
1293	1268		not require a pharmacy or pharmacy services administrative
1294	1269		organization to log into a system to upload individual claim appeals
1295	1270		or to download individual appeal responses. If a price update is
1296	1271		warranted, the pharmacy benefits manager shall make the change in
1297	1272		the reimbursement amount, permit the dispensing pharmacy to reverse
1298	1273
1299		-	SB993 HFLR Page 26
1300		-	BOLD FACE denotes Committee Amendments. 1
	1274	+	Req. No. 13515 Page 26 1
1301	1275		2
1302	1276		3
1303	1277		4
1304	1278		5
1305	1279		6
1306	1280		7
1307	1281		8
1308	1282		9
1309	1283		10
1310	1284		11
1311	1285		12
1312	1286		13
1313	1287		14
1314	1288		15
1315	1289		16
1316	1290		17
1317	1291		18
1318	1292		19
1319	1293		20
1320	1294		21
1321	1295		22
1322	1296		23
1323	1297		24
1324	1298
1325	1299		and rebill the claim in question, and make the reimbursement amount
1326	1300		change retroactive and effective for all contracted prov iders; and
1327	1301		5. If a below-cost reimbursement appeal is denied, the PBM
1328	1302		shall provide the reason for the denial, including the National Drug
1329	1303		Code (NDC) number from, and the name of, the specific national or
1330	1304		regional wholesalers doing business in this state where the drug is
1331	1305		currently in stock and available for purchase by the dispensing
1332	1306		pharmacy at a price below the PBM’s reimbursement price. The PBM
1333	1307		shall include documented proof from the specific national or
1334	1308		regional wholesalers doing business in this sta te showing that the
1335	1309		drug is currently in stock and available for purchase by the
1336	1310		dispensing pharmacy at a price below the PBM’s reimbursement price.
1337	1311		If the NDC number provided by the pharmacy benefits manager is not
1338	1312		available below the acquisition cost ob tained from the
1339	1313		pharmaceutical wholesaler from whom the dispensing pharmacy
1340	1314		purchases the majority of the prescription drugs that are dispensed,
1341	1315		the pharmacy benefits manager shall immediately adjust the
1342	1316		reimbursement amount, permit the dispensing pharmacy to reverse and
1343	1317		rebill the claim in question, and make the reimbursement amount
1344	1318		adjustment retroactive and effective for all contracted providers ;
1345	1319		6. Any appeal that results in an increase in the reimbursement
1346	1320		from the PBM that continues to be below the p harmacy’s acquisition
1347	1321		cost shall be considered a denial under this section. Any denial of
1348	1322
1349		-	SB993 HFLR Page 27
1350		-	BOLD FACE denotes Committee Amendments. 1
	1323	+	Req. No. 13515 Page 27 1
1351	1324		2
1352	1325		3
1353	1326		4
1354	1327		5
1355	1328		6
1356	1329		7
1357	1330		8
1358	1331		9
1359	1332		10
1360	1333		11
1361	1334		12
1362	1335		13
1363	1336		14
1364	1337		15
1365	1338		16
1366	1339		17
1367	1340		18
1368	1341		19
1369	1342		20
1370	1343		21
1371	1344		22
1372	1345		23
1373	1346		24
1374	1347
1375	1348		an appeal shall follow the requirements of paragraph 5 of this
1376	1349		subsection; and
1377	1350		7. The PBM shall not require a pharmacy to collect additional
1378	1351		monies following a succ essful below-cost reimbursement appeal from
1379	1352		any person or entity other than the PBM who adjudicated the drug
1380	1353		claim, including the patient or plan sponsor .
1381	1354		B. The reimbursement appeal requirements in this section shall
1382	1355		apply to all drugs, medical products, or devices reimbursed
1383	1356		according to any payment methodology, including, but not limited to:
1384	1357		1. Average acquisition cost, including the National Average
1385	1358		Drug Acquisition Cost;
1386	1359		2. Average manufacturer price;
1387	1360		3. Average wholesale price;
1388	1361		4. Brand effective rate or generic effective rate;
1389	1362		5. Discount indexing;
1390	1363		6. Federal upper limits;
1391	1364		7. Wholesale acquisition cost; and
1392	1365		8. Any other term that a pharmacy benefits manager or an
1393	1366		insurer of a health benefit plan may use to establish reimbursement
1394	1367		rates to a pharmacist or pharmacy for pharmacist services.
1395	1368		C. The pharmacy benefits manager shall not place a drug on a
1396	1369		MAC list, unless there are at least two therapeutically equivalent,
1397	1370		multiple-source drugs, generally available for purchase by
1398	1371		dispensing retail ph armacies from national or regional wholesalers.
1399	1372
1400		-	SB993 HFLR Page 28
1401		-	BOLD FACE denotes Committee Amendments. 1
	1373	+	Req. No. 13515 Page 28 1
1402	1374		2
1403	1375		3
1404	1376		4
1405	1377		5
1406	1378		6
1407	1379		7
1408	1380		8
1409	1381		9
1410	1382		10
1411	1383		11
1412	1384		12
1413	1385		13
1414	1386		14
1415	1387		15
1416	1388		16
1417	1389		17
1418	1390		18
1419	1391		19
1420	1392		20
1421	1393		21
1422	1394		22
1423	1395		23
1424	1396		24
1425	1397
1426	1398		D. In the event that a drug is placed on the FDA Drug Shortages
1427	1399		Database, pharmacy benefits managers shall reimburse claims to
1428	1400		pharmacies at no less than the wholesale acquisition cost for the
1429	1401		specific NDC number being dispensed.
1430	1402		E. The pharmacy benefits manager shall not require
1431	1403		accreditation or licensing of providers, or any entity licensed or
1432	1404		regulated by the State Board of Pharmacy, other than by the State
1433	1405		Board of Pharmacy or federal government entity a s a condition for
1434	1406		participation as a network provider.
1435	1407		F. A pharmacy or pharmacist may decline to provide the
1436	1408		pharmacist clinical or dispensing services to a patient or pharmacy
1437	1409		benefits manager if the pharmacy or pharmacist is to be paid less
1438	1410		than the pharmacy’s cost for providing the pharmacist clinical or
1439	1411		dispensing services.
1440	1412		G. The pharmacy benefits manager shall provide a dedicated
1441	1413		telephone number, email address and names of the personnel with
1442	1414		decision-making authority regarding MAC appeals and pric ing.
1443	1415		SECTION 9. NEW LAW A new section of law to be codified
1444	1416		in the Oklahoma Statutes as Section 360.1 of Title 59, unless there
1445	1417		is created a duplication in numbering, reads as follows:
1446	1418		A. If a disaster declaration is issued for a c ounty in this
1447	1419		state, the time period for a provider, a provider ’s representative,
1448	1420		or a pharmacy service administrative organization to file a below -
1449	1421		cost reimbursement appeal pursuant to Section 360 of Title 59 of the
1450	1422
1451		-	SB993 HFLR Page 29
1452		-	BOLD FACE denotes Committee Amendments. 1
	1423	+	Req. No. 13515 Page 29 1
1453	1424		2
1454	1425		3
1455	1426		4
1456	1427		5
1457	1428		6
1458	1429		7
1459	1430		8
1460	1431		9
1461	1432		10
1462	1433		11
1463	1434		12
1464	1435		13
1465	1436		14
1466	1437		15
1467	1438		16
1468	1439		17
1469	1440		18
1470	1441		19
1471	1442		20
1472	1443		21
1473	1444		22
1474	1445		23
1475	1446		24
1476	1447
1477	1448		Oklahoma Statutes shall be tolled for t he duration of the disaster
1478	1449		declaration.
1479	1450		B. Upon the expiration of the disaster declaration, the tolling
1480	1451		of the filing period for below -cost reimbursement appeals shall
1481	1452		continue for an additional thirty (30) calendar days. Afterward,
1482	1453		the time period for filing a below-cost reimbursement appeal, as
1483	1454		otherwise provided under state law, shall resume.
1484	1455		C. The tolling provisions of this section shall apply only to
1485	1456		continuing counties included in the declared disaster area and to
1486	1457		below-cost reimbursement appeals arising from claims impacted during
1487	1458		the time period of the declared disaster.
1488	1459		D. A pharmacy benefits manager (PBM) shall not deny a below -
1489	1460		cost reimbursement appeal on timeliness if such appeal is filed
1490	1461		during the tolled period provided in this section.
1491	1462		E. The Attorney General may promulgate rules to implement the
1492	1463		provisions of this act.
1493	1464		SECTION 10. It being immediately necessary for the preservation
1494	1465		of the public peace, health or safety, an emergency is hereby
1495	1466		declared to exist, by reason whereof this act shall take effect and
1496	1467		be in full force from and after its passage and approval.
1497	1468
1498		-	COMMITTEE REPORT BY: COMMITTEE ON HEALTH AND HUMAN SERVICES
1499		-	OVERSIGHT, dated 04/16/2025 - DO PASS, As Amended.
	1469	+	60-1-13515 TJ 04/15/25
	1470	+
	1471	+