PBM must include in contracts the sources utilized to determine the MAC pricing of the pharmacy update MAC pricing at least eveery 7 days and establish a process for providers to readily access the MAC list specific to that provider the reimbursement amount. Provide appeals procedure for provider or a provider’s representative to contest reimbursement amounts within 10 days of the final adjusted payment date. PBM must respond within 10 days. If a price update is warranted, PBM must make the change in the reimbursement amount, permit challenging pharmacy to reverse and rebill the claim in question, and make the reimbursement amount change effective for each similarly contracted Oklahoma provider; and if the reimbursement appeal is denied, PBM must provide the reason for the denial, including the NDC number from wholesalers where drug is generally available for purchase by pharmacies in the state at or below the PBM’s reimbursement.

Link to Existing Law: 59 Okl.St.Ann. § 360

This state is different than most with its mention and definition of a reasonable appeals procedure. However, given the appeal can only be made to the PBM, there is opportunity to advocate for a stronger regulatory scheme and oversight of PBM.