{"data":{"id":"us-ok/okla.-stat.-tit.-59-59-360v1","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 59, § 59-360v1","heading":"Pharmacy benefits manager – Contractual duties to","body":"provider.\n\nA. The pharmacy benefits manager shall, with respect to\n\ncontracts between a pharmacy benefits manager and a provider,\n\nincluding a pharmacy service administrative organization:\n\nl. Include in such contracts the specific sources utilized to\n\ndetermine the maximum allowable cost (MAC) pricing of the pharmacy,\n\nupdate MAC pricing at least every seven (7) calendar days, and\n\nestablish a process for providers to readily access the MAC list\n\nspecific to that provider;\n\n2. In order to place a drug on the MAC list, ensure that the\n\ndrug is listed as “A” or “B” rated in the most recent version of the\n\nUnited States Food and Drug Administration (FDA) Approved Drug\n\nProducts with Therapeutic Equivalence Evaluations, also known as the\n\nOrange Book, and the drug is generally available for purchase by\n\npharmacies in the state from national or regional wholesalers and is\n\nnot obsolete;\n\n3. Ensure dispensing fees are not included in the calculation\n\nof MAC price reimbursement to pharmacy providers;\n\n4. Provide a reasonable administration appeals procedure to\n\nallow a provider, a provider’s representative and a pharmacy service\n\nadministrative organization to contest reimbursement amounts within\n\nfourteen (14) calendar days of the final adjusted payment date. The\n\npharmacy benefits manager shall not prevent the pharmacy or the\n\npharmacy service administrative organization from filing\n\nreimbursement appeals in an electronic batch format. The pharmacy\n\nbenefits manager must respond to a provider, a provider’s\n\nrepresentative and a pharmacy service administrative organization\n\nwho have contested a reimbursement amount through this procedure\n\nwithin ten (10) calendar days. The pharmacy benefits manager must\n\nrespond in an electronic batch format to reimbursement appeals filed\n\nin an electronic batch format. The pharmacy benefits manager shall\n\nnot require a pharmacy or pharmacy services administrative\n\norganization to log into a system to upload individual claim appeals\n\nor to download individual appeal responses. If a price update is\n\nwarranted, the pharmacy benefits manager shall make the change in\n\nthe reimbursement amount, permit the dispensing pharmacy to reverse\n\nand rebill the claim in question, and make the reimbursement amount\n\nchange retroactive and effective for all contracted providers;\n\n5. If a below-cost reimbursement appeal is denied, the PBM\n\nshall provide the reason for the denial, including the National Drug\n\nCode (NDC) number from, and the name of, the specific national or\n\nregional wholesalers doing business in this state where the drug is\n\ncurrently in stock and available for purchase by the dispensing\n\npharmacy at a price below the PBM’s reimbursement price. The PBM\n\nshall include documented proof from the specific national or\n\nregional wholesalers doing business in this state showing that the\n\ndrug is currently in stock and available for purchase by the\n\ndispensing pharmacy at a price below the PBM’s reimbursement price.\n\nIf the NDC number provided by the pharmacy benefits manager is not\n\navailable below the acquisition cost obtained from the\n\npharmaceutical wholesaler from whom the dispensing pharmacy\n\npurchases the majority of the prescription drugs that are dispensed,\n\nthe pharmacy benefits manager shall immediately adjust the\n\nreimbursement amount, permit the dispensing pharmacy to reverse and\n\nrebill the claim in question, and make the reimbursement amount\n\nadjustment retroactive and effective for all contracted providers;\n\n6. Any appeal that results in an increase in the reimbursement\n\nfrom the PBM that continues to be below the pharmacy’s acquisition\n\ncost shall be considered a denial under this section. Any denial of\n\nan appeal shall follow the requirements of paragraph 5 of this\n\nsubsection; and\n\n7. The PBM shall not require a pharmacy to collect additional\n\nmonies following a successful below-cost reimbursement appeal from\nal that results in an increase in the reimbursement\n\nfrom the PBM that continues to be below the pharmacy’s acquisition\n\ncost shall be considered a denial under this section. Any denial of\n\nan appeal shall follow the requirements of paragraph 5 of this\n\nsubsection; and\n\n7. The PBM shall not require a pharmacy to collect additional\n\nmonies following a successful below-cost reimbursement appeal from\n\nany person or entity other than the PBM who adjudicated the drug\n\nclaim, including the patient or plan sponsor.\n\nB. The reimbursement appeal requirements in this section shall\n\napply to all drugs, medical products, or devices reimbursed\n\naccording to any payment methodology, including, but not limited to:\n\n1. Average acquisition cost, including the National Average\n\nDrug Acquisition Cost;\n\n2. Average manufacturer price;\n\n3. Average wholesale price;\n\n4. Brand effective rate or generic effective rate;\n\n5. Discount indexing;\n\n6. Federal upper limits;\n\n7. Wholesale acquisition cost; and\n\n8. Any other term that a pharmacy benefits manager or an\n\ninsurer of a health benefit plan may use to establish reimbursement\n\nrates to a pharmacist or pharmacy for pharmacist services.\n\nC. The pharmacy benefits manager shall not place a drug on a\n\nMAC list, unless there are at least two therapeutically equivalent,\n\nmultiple-source drugs, generally available for purchase by\n\ndispensing retail pharmacies from national or regional wholesalers.\n\nD. In the event that a drug is placed on the FDA Drug Shortages\n\nDatabase, pharmacy benefits managers shall reimburse claims to\n\npharmacies at no less than the wholesale acquisition cost for the\n\nspecific NDC number being dispensed.\n\nE. The pharmacy benefits manager shall not require\n\naccreditation or licensing of providers, or any entity licensed or\n\nregulated by the State Board of Pharmacy, other than by the State\n\nBoard of Pharmacy or federal government entity as a condition for\n\nparticipation as a network provider.\n\nF. A pharmacy or pharmacist may decline to provide the\n\npharmacist clinical or dispensing services to a patient or pharmacy\n\nbenefits manager if the pharmacy or pharmacist is to be paid less\n\nthan the pharmacy’s cost for providing the pharmacist clinical or\n\ndispensing services.\n\nG. The pharmacy benefits manager shall provide a dedicated\n\ntelephone number, email address and names of the personnel with\n\ndecision-making authority regarding MAC appeals and pricing.","path":["OK Code","Title 59"],"source_url":"https://www.oklegislature.gov/OK_Statutes/CompleteTitles/os59.pdf","current_through":"2026-08-14","vintage":"open-us-law v2026.08, retrieved 2026-09-14","retrieved_at":"2026-09-14T18:32:36Z","sha256":"57790ad89aee9faa8e9a0a7e3ce0bb09d9e13e9b7be0268fd091e99fd19a209c","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-59-59-360.1","next":"us-ok/okla.-stat.-tit.-59-59-360v2"},"notice":"GroundRules: Original legal text. Not legal advice."}