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. 21.27.925. 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. 21.27.930. Pharmacy audit appeal; future repayment.
(a) A pharmacy benefits manager conducting an audit shall establish a written appeals process. (b) Recoupment of disputed funds or repayment of funds to the pharmacy benefits manager by the pharmacy, if permitted by contract, shall occur, to the extent demonstrated or documented in the pharmacy audit findings, after final internal disposition of the audit, […]
Sec. 21.27.935. Fraudulent activity.
When a pharmacy benefits manager conducts an audit of a pharmacy, the pharmacy benefits manager may not consider unintentional clerical or record-keeping errors, including typographical errors, writer’s errors, or computer errors regarding a required document or record, to be fraudulent activity. In this section, “fraudulent activity” means an intentional act of theft, deception, misrepresentation, or […]
Sec. 21.27.901. Registration of pharmacy benefits managers; scope of business practice.
(a) A person may not conduct business in the state as a pharmacy benefits manager unless the person is registered with the director as a third-party administrator under AS 21.27.630. (b) A pharmacy benefits manager registered under AS 21.27.630 may (1) contract with an insurer to administer or manage pharmacy benefits provided by an insurer […]
Sec. 21.27.905. Renewal of registration.
(a) A pharmacy benefits manager shall biennially renew a registration with the director. (b) To renew a registration under this section, a pharmacy benefits manager shall pay a renewal fee established by the director. The director shall set the amount of the renewal fee to allow the renewal and oversight activities of the division to […]
Sec. 21.27.910. Pharmacy audit procedural requirements.
(a) When a pharmacy benefits manager conducts an audit of the records of a pharmacy, the period covered by the audit of a claim may not exceed two years from the date that the claim was submitted to or adjudicated by the pharmacy benefits manager, whichever is earlier. Except as required under AS 21.36.495, a […]