AS 21.27.915: Overpayment or underpayment.

(a) When a pharmacy benefits manager conducts an audit of a pharmacy, the pharmacy benefits manager shall base a finding of overpayment or underpayment by the pharmacy on the actual overpayment or underpayment and not on a projection based on the number of patients served having a similar diagnosis or on the number of similar orders or refills for similar drugs, except as provided in (b) of this section.

(b) A pharmacy benefits manager may resolve a finding of overpayment or underpayment by entering into a settlement agreement with the pharmacy. The settlement agreement

(1) must comply with the requirements of AS 21.36.125; and

(2) may be based on a statistically justifiable projection method.

(c) A pharmacy benefits manager may not include the dispensing fee amount in a finding of an overpayment unless

(1) a prescription was not actually dispensed;

(2) the prescriber denied authorization;

(3) the prescription dispensed was a medication error by the pharmacy; or

(4) the identified overpayment is solely based on an extra dispensing fee.