PBMs must include in all contracts between a PBM and a pharmacy (1) the sources utilized to determine multiple source generic drug pricing, including, if applicable, the MAC pricing formula; (2) a requirement to update that pricing information every seven days; (3) a reasonable process for pharmacies to access MAC pricing lists in a timely manner. In addition, in creating the MAC lists, PBMs must, at a minimum, ensure that the drug is listed as therapeutically and pharmaceutically equivalent or “A,” “B,” “NR,” or “NA” rated by the FDA, and that the drug is available for purchase without limitations by all pharmacies in the State from national or regional wholesalers and is not obsolete or temporarily unavailable. In addition, PBMs must provide a process to appeal, investigate, and resolve disputes regarding MAC drug pricing, including the right to appeal within 14 days following the initial claim, with such appeals must be resolved by the PBM within 14 days. If the appeal is denied, the PBM must provide the reason for the denial and identify the NDC of a drug that is available for purchase by contracted pharmacies in NJ005C9B from registered wholesalers at a price which is equal to or less than the MAC for the appealed drug as determined by the PBM.

Link to Existing Law: N.J.S.A. 17B:27F-1 et seq.

Given the appeal can only be made to the PBM, there is opportunity to advocate for a stronger regulatory scheme and oversight of PBM.