Sec. 21.27.940. Pharmacy audits; restrictions.
The requirements of AS 21.27.901 – 21.27.955 do not apply to an audit (1) in which suspected fraudulent activity or other intentional or wilful misrepresentation is evidenced by a physical review, a review of claims data, a statement, or another investigative method; or (2) of claims paid for under the medical assistance program under AS […]
Sec. 21.27.945. Drug pricing list; procedural requirements.
(a) A pharmacy benefits manager shall (1) make available to each network pharmacy at the beginning of the term of the network pharmacy’s contract, and upon renewal of the contract, the methodology and sources used to determine the drug pricing list; (2) provide a telephone number at which a network pharmacy may contact an employee […]
Sec. 21.27.950. Multi-source generic drug appeal.
(a) A pharmacy benefits manager shall establish a process by which a network pharmacy, or a network pharmacy’s contracting agent, may appeal the reimbursement for a multi-source generic drug. A pharmacy benefits manager shall resolve an appeal from a network pharmacy within 10 calendar days after the network pharmacy or the contracting agent submits the […]
Sec. 21.27.955. Definitions.
In AS 21.27.901 – 21.27.955, (1) “audit” means an official examination and verification of accounts and records; (2) “claim” means a request from a pharmacy or pharmacist to be reimbursed for the cost of filling or refilling a prescription for a drug or for providing a medical supply or device; (3) “extrapolation” means the practice […]
Sec. 21.27.990. Definitions.
In this chapter, (1) “accredited state” means a state in which the insurance department or regulatory agency of that state has qualified as meeting the minimum financial regulatory standards adopted and established by the National Association of Insurance Commissioners; (2) “affiliate” or “affiliated” has the meaning given in AS 21.22.200; (3) “appointment” means an act […]
Sec. 21.27.730. Reinsurance intermediary manager qualifications.
In addition to the general qualifications under AS 21.27.020, the director may require that a reinsurance intermediary manager maintain (1) a bond in an amount acceptable to the director that requires the reinsurance intermediary manager to conduct business under this title; and (2) an errors and omissions insurance policy acceptable to the director.
Sec. 21.27.920. Recoupment.
(a) When a pharmacy benefits manager conducts an audit of a pharmacy, the pharmacy benefits manager shall base the recoupment of overpayments on the actual overpayment of the claim, except as provided in AS 21.27.915(b). (b) A pharmacy benefits manager conducting an audit of a pharmacy may not (1) use extrapolation in calculating recoupments or […]
Sec. 21.27.750. Authority of reinsurance intermediary managers.
A reinsurance intermediary manager has only the authority that is consistent with this title and that is conferred by the reinsurer. A reinsurance intermediary manager, resident or nonresident, qualified and licensed under this chapter, may exercise the powers conferred by this title upon insurance producers and independent adjusters only for the kinds or classes of […]
Sec. 21.27.925. Pharmacy audit reports.
(a) A pharmacy benefits manager shall deliver a preliminary audit report to the pharmacy audited within 60 days after the conclusion of the audit. (b) A pharmacy benefits manager shall allow the pharmacy at least 30 days following receipt of the preliminary audit report to provide documentation to the pharmacy benefits manager to address a […]
Sec. 21.27.760. Operating requirements for reinsurance intermediary managers; actions for loss.
(a) A reinsurer may not transact business with a reinsurance intermediary manager unless there is in effect a written contract approved by the reinsurer’s board of directors between the parties that establishes the responsibilities of each party, indicates each party’s share of responsibility for each particular function, and specifies the division of responsibilities. (b) The […]