(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.
Structure Alaska Statutes
Chapter 27. Producers, Agents, Administrators, Brokers, Adjusters, and Managers
Article 9. Pharmacy Benefits Managers.
Sec. 21.27.901. Registration of pharmacy benefits managers; scope of business practice.
Sec. 21.27.905. Renewal of registration.
Sec. 21.27.910. Pharmacy audit procedural requirements.
Sec. 21.27.915. Overpayment or underpayment.
Sec. 21.27.925. Pharmacy audit reports.
Sec. 21.27.930. Pharmacy audit appeal; future repayment.
Sec. 21.27.935. Fraudulent activity.
Sec. 21.27.940. Pharmacy audits; restrictions.
Sec. 21.27.945. Drug pricing list; procedural requirements.