INDIANA SUMMARY OF EXISTING LAW

(a) A PBM must: (1) Identify to contracted: (A) PSAOs; or (B) pharmacies if the PBM contracts directly with pharmacies; the sources used by the PBM to calculate the drug product reimbursement paid for covered drugs available under the pharmacy health benefit plan administered by the PBM. (2) Establish an appeal process for pharmacies to appeal and resolve disputes concerning the MAC pricing. (3) Update and make available to pharmacies: (A) at least every 45 days; or (B) in a different time frame if contracted between a PBM and a pharmacy; the PBM’s MAC list. (b) The appeal process required by subsection (a)(2) must include the following: (1) The right to appeal a claim not to 60 days following the initial filing of the claim. (2) The investigation and resolution of a filed appeal by the PBM in a time frame determined by the commissioner. (3) If an appeal is denied, a requirement that the PBM provide the reason for the denial. (4) If an appeal is approved, a requirement that the PBM do the following: (A) Change the MAC of the drug for the pharmacy that filed the appeal as of the initial date of service that the appealed drug was dispensed. (B) Adjust the MAC of the drug for the appealing pharmacy and for all other contracted pharmacies in the same network of the PBM that filled a prescription for patients covered under the same health benefit plan beginning on the initial date of service the appealed drug was dispensed. (C) Adjust the drug product reimbursement for contracted pharmacies that resubmit claims to reflect the adjusted MAC, if applicable. (D) Allow the appealing pharmacy and all other contracted pharmacies in the network that filled the prescriptions for patients covered under the same health benefit plan to reverse and resubmit claims and receive payment based on the adjusted MAC from the initial date of service the appealed drug was dispensed. (E) Make retroactive price adjustments in the next payment cycle unless otherwise agreed to by the pharmacy.

Link to Existing Law: IN ST 27-1-24.5-22

Practical Note for Existing Law

This is a strong MAC law with favorable appeal rights for a pharmacy including up to 60 days to file the MAC appeal.