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1 STATE OF OKLAHOMA
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2 2nd Session of the 60th Legislature (2026)
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3 SENATE BILL 2074 By: Alvord
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6 AS INTRODUCED
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7 An Act relating to pharmacy benefits managers;
7 amending 59 O.S. 2021, Sections 357, as last amended
8 by Section 2, Chapter 414, O.S.L. 2025, and 360, as
8 last amended by Section 8, Chapter 300, O.S.L. 2025
9 (59 O.S. Supp. 2025, Sections 357 and 360), which
9 relate to definitions and pharmacy benefits manager
10 contractual duties to provider; defining term;
10 prohibiting certain pharmacy benefits manager from
11 refusing to accept certain documentation; requiring
11 certain adjusted reimbursement amount if certain
12 appeal is approved; allowing certain provider to
12 request certain reversal or rebilling; requiring
13 certain information to be included in certain appeal;
13 requiring certain adjustments to include certain
14 claim-level details within certain time period;
14 prohibiting certain reimbursement amounts; updating
15 statutory references; updating statutory language;
15 and providing an effective date.
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18 BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
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19 SECTION 1. AMENDATORY 59 O.S. 2021, Section 357, as last
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20 amended by Section 2, Chapter 414, O.S.L. 2025 (59 O.S. Supp. 2025,
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21 Section 357), is amended to read as follows:
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22 Section 357. A. As used in Sections 357 through 360 360.1 of
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23 this title:
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1 1. "Acquisition cost" means the total amount paid by a provider
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2 to acquire a drug, medical product, or device at the time of
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3 purchase as evidenced by verifiable purchase documentation such as
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4 an invoice or electronic price file. Acquisition cost shall include
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5 purchase price, procurement fees, and associated shipping or
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6 handling charges and shall not include any post-purchase rebates,
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7 discounts, or credits that are not guaranteed and applied at the
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8 time of sale;
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9 2. "Covered entity" means a nonprofit hospital or medical
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10 service organization, for-profit hospital or medical service
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11 organization, insurer, health benefit plan, health maintenance
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12 organization, health program administered by the state in the
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13 capacity of providing health coverage, or an employer, labor union,
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14 or other group of persons that provides health coverage to persons
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15 in this state. This term does not include a health benefit plan
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16 that provides coverage only for accidental injury, specified
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17 disease, hospital indemnity, disability income, or other limited
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18 benefit health insurance policies and contracts that do not include
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19 prescription drug coverage;
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20 2. 3. "Covered individual" means a member, participant,
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21 enrollee, contract holder or policy holder or beneficiary of a
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22 covered entity who is provided health coverage by the covered
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23 entity. A covered individual includes any dependent or other person
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Req. No. 2584 Page 2
1 provided health coverage through a policy, contract or plan for a
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2 covered individual;
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3 3. 4. "Department" means the Insurance Department;
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4 4. 5. "Effective rate contracting" means any agreement or
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5 arrangement between a pharmacy or contracting agent acting on behalf
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6 of a pharmacy and a pharmacy benefits manager for pharmaceuticals
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7 based on the effective rate of payment rather than a predetermined
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8 fixed price or fixed discount percentage;
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9 5. 6. "Maximum allowable cost", "MAC", or "MAC list" means the
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10 list of drug products delineating the maximum per-unit reimbursement
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11 for multiple-source prescription drugs, medical product products, or
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12 device devices;
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13 6. 7. "Multisource drug product reimbursement" (reimbursement)
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14 means the total amount paid to a pharmacy inclusive of any reduction
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15 in payment to the pharmacy, excluding prescription dispense fees and
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16 professional fees;
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17 7. 8. "Office" means the Office of the Attorney General;
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18 8. 9. "Pharmacy benefits management" means a service provided
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19 to covered entities to facilitate the provision of prescription drug
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20 benefits to covered individuals within the state, including
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21 negotiating pricing and other terms with drug manufacturers and
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22 providers. Pharmacy benefits management may include any or all of
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23 the following services:
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1 a. claims processing, retail network management and
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2 payment of claims to pharmacies for prescription drugs
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3 dispensed to covered individuals,
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4 b. clinical formulary development and management
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5 services, or
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6 c. rebate contracting and administration;
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7 9. 10. "Pharmacy benefits manager" or "PBM" means a person,
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8 business, or other entity that performs pharmacy benefits
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9 management. The term shall include a person or entity acting on
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10 behalf of a PBM in a contractual or employment relationship in the
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11 performance of pharmacy benefits management for a managed care
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12 company, nonprofit hospital, medical service organization, insurance
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13 company, third-party payor, or a health program administered by an
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14 agency or department of this state;
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15 10. 11. "Plan sponsor" means the employers, insurance
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16 companies, unions and health maintenance organizations or any other
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17 entity responsible for establishing, maintaining, or administering a
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18 health benefit plan on behalf of covered individuals; and
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19 11. 12. "Provider" means a pharmacy licensed by the State Board
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20 of Pharmacy, or an agent or representative of a pharmacy, including,
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21 but not limited to, the pharmacy's contracting agent, which
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22 dispenses prescription drugs or devices to covered individuals.
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23 B. Nothing in the definition of pharmacy benefits management or
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24 pharmacy benefits manager in the Patient's Right to Pharmacy Choice
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1 Act, Pharmacy Audit Integrity Act, or Sections 357 through 360 360.1
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2 of this title shall deem an employer a "pharmacy benefits manager"
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3 of its own self-funded health benefit plan, except, to the extent
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4 permitted by applicable law, where the employer, without the
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5 utilization of a third party and unrelated to the employer's own
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6 pharmacy:
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7 a. negotiates 1. Negotiates directly with drug
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8 manufacturers,;
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9 b. processes 2. Processes claims on behalf of its members,;
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10 or
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11 c. manages 3. Manages its own retail network of pharmacies.
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12 SECTION 2. AMENDATORY 59 O.S. 2021, Section 360, as last
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13 amended by Section 8, Chapter 300, O.S.L. 2025 (59 O.S. Supp. 2025,
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14 Section 360), is amended to read as follows:
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15 Section 360. A. The pharmacy benefits manager (PBM) shall,
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16 with respect to contracts between a pharmacy benefits manager and a
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17 provider, including a pharmacy service administrative organization:
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18 l. Include in such contracts the specific sources utilized to
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19 determine the maximum allowable cost (MAC) pricing of the pharmacy,
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20 update MAC pricing at least every seven (7) calendar days, and
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21 establish a process for providers to readily access the MAC list
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22 specific to that provider;
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23 2. In order to place a drug on the MAC list, ensure that the
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24 drug is listed as "A" or "B" rated in the most recent version of the
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1 United States Food and Drug Administration (FDA) Approved Drug
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2 Products with Therapeutic Equivalence Evaluations, also known as the
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3 Orange Book, and the drug is generally available for purchase by
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4 pharmacies in the state from national or regional wholesalers and is
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5 not obsolete;
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6 3. Ensure dispensing fees are not included in the calculation
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7 of MAC price reimbursement to pharmacy providers;
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8 4. Provide a reasonable administration appeals procedure to
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9 allow a provider, a provider's representative and a pharmacy service
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10 administrative organization to contest reimbursement amounts within
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11 fourteen (14) calendar days of the final adjusted payment date. The
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12 pharmacy benefits manager shall not prevent the pharmacy or the
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13 pharmacy service administrative organization from filing
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14 reimbursement appeals in an electronic batch format. The pharmacy
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15 benefits manager must PBM shall respond to a provider, a provider's
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16 representative and a pharmacy service administrative organization
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17 who have contested a reimbursement amount through this procedure
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18 within ten (10) calendar days. The pharmacy benefits manager must
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19 PBM shall respond in an electronic batch format to reimbursement
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20 appeals filed in an electronic batch format. The pharmacy benefits
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21 manager PBM shall not require a pharmacy or pharmacy services
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22 administrative organization to log into a system to upload
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23 individual claim appeals or to download individual appeal responses.
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24 A PBM shall not refuse to accept additional documentation from
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Req. No. 2584 Page 6
1 providers after the appeal submission. If a price update is
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2 warranted, the pharmacy benefits manager PBM shall make the change
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3 in the reimbursement amount, permit the dispensing pharmacy to
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4 reverse and rebill the claim in question, and make the reimbursement
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5 amount change retroactive and effective for all contracted
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6 providers;
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7 5. If a below-cost reimbursement appeal is denied, the PBM
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8 shall provide the reason for the denial, including the National Drug
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9 Code (NDC) number from, and the name of, the specific national or
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10 regional wholesalers doing business in this state where the drug is
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11 currently in stock and available for purchase by the dispensing
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12 pharmacy at a price below the PBM's reimbursement price. The PBM
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13 shall include documented proof from the specific national or
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14 regional wholesalers doing business in this state showing that the
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15 drug is currently in stock and available for purchase by the
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16 dispensing pharmacy at a price below the PBM's reimbursement price.;
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17 6. If the NDC number provided by the pharmacy benefits manager
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18 PBM is not available below the acquisition cost obtained from the
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19 pharmaceutical wholesaler from whom the dispensing pharmacy
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20 purchases the majority of the prescription drugs that are dispensed,
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21 the pharmacy benefits manager PBM shall immediately adjust the
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22 reimbursement amount, permit the dispensing pharmacy to reverse and
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23 rebill the claim in question, and make the reimbursement amount
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24 adjustment retroactive and effective for all contracted providers;
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1 effective for all prescriptions of the appealed drug, medical
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2 product, or device for patients covered under the same Bank
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3 Identification Number (BIN) and Processor Control Number (PCN),
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4 retroactive to the initially appealed claim's date of service. A
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5 PBM shall notify the provider that an increase has been granted
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6 because of a reimbursement appeal. If a claim subject to an
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7 approved appeal is not reversed and reprocessed within thirty (30)
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8 calendar days after the final appeal determination, the PBM shall
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9 remit to the provider the full reimbursement amount required by the
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10 approved appeal, including any retroactive adjustments and shall not
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11 require the provider to refund or otherwise return any portion of
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12 the reimbursement paid for that claim;
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13 6. 7. Any appeal that results in an increase in the
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14 reimbursement from the PBM that continues to be below the pharmacy's
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15 acquisition cost shall be considered a denial under this section.
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16 Any denial of an appeal shall follow the requirements of paragraph
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17 paragraphs 5 and 6 of this subsection; and
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18 7. 8. The PBM shall not require a pharmacy to collect
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19 additional monies following a successful below-cost reimbursement
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20 appeal from any person or entity other than the PBM who adjudicated
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21 the drug claim, including the patient or plan sponsor; and
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22 9. Any adjustment to provider reimbursement shall be
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23 accompanied by complete claim-level detail sufficient to reconcile
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24 the adjustment, including identification of the original claim
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Req. No. 2584 Page 8
1 payment values and the revised values for all affected fields. An
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2 adjustment for which such claim-level detail is not provided
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3 contemporaneously shall be deemed incomplete.
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4 B. The reimbursement appeal requirements in this section shall
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5 apply to all drugs, medical products, or devices reimbursed
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6 according to any payment methodology, including, but not limited to:
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7 1. Average acquisition cost, including the National Average
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8 Drug Acquisition Cost;
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9 2. Average manufacturer price;
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10 3. Average wholesale price;
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11 4. Brand effective rate or generic effective rate;
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12 5. Discount indexing;
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13 6. Federal upper limits;
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14 7. Wholesale acquisition cost; and
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15 8. Any other term that a pharmacy benefits manager PBM or an
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16 insurer of a health benefit plan may use to establish reimbursement
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17 rates to a pharmacist or pharmacy for pharmacist services.
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18 C. The pharmacy benefits manager PBM shall not place a drug on
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19 a MAC list, unless there are at least two therapeutically
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20 equivalent, multiple-source drugs, generally available for purchase
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21 by dispensing retail pharmacies from national or regional
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22 wholesalers.
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23 D. In the event that a drug is placed on the FDA Drug Shortages
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24 Database, pharmacy benefits managers PBMs shall reimburse claims to
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Req. No. 2584 Page 9
1 pharmacies at no less than the wholesale acquisition cost for the
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2 specific NDC number being dispensed.
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3 E. The pharmacy benefits manager PBM shall not require
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4 accreditation or licensing of providers, or any entity licensed or
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5 regulated by the State Board of Pharmacy, other than by the State
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6 Board of Pharmacy or federal government entity as a condition for
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7 participation as a network provider.
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8 F. A pharmacy or pharmacist may decline to provide the
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9 pharmacist clinical or dispensing services to a patient or pharmacy
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10 benefits manager if the pharmacy or pharmacist is to be paid less
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11 than the pharmacy's cost for providing the pharmacist clinical or
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12 dispensing services.
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13 G. The pharmacy benefits manager PBM shall provide a dedicated
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14 telephone number, email address and names of the personnel with
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15 decision-making authority regarding MAC appeals and pricing.
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16 H. A PBM shall not reimburse a provider for a prescription drug
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17 or pharmacy service in an amount less than the national average drug
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18 acquisition cost for the prescription drug or pharmacy service at
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19 the time the drug is administered or dispensed, plus a professional
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20 dispensing fee of no less than the Medicaid fee-for-service
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21 professional dispensing fee rate established under rules promulgated
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22 by the Oklahoma Health Care Authority Board. If the national
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23 average drug acquisition cost is not available at the time a drug is
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24 administered or dispensed, a PBM shall not reimburse in an amount
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Req. No. 2584 Page 10
1 that is less than the wholesale acquisition cost of the drug
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2 pursuant to 42 U.S.C., Section 1395w-3a(c)(6)(B), and shall
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3 reimburse a professional dispensing fee of no less than the rate
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4 established by the Board.
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5 SECTION 3. This act shall become effective November 1, 2026.
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7 60-2-2584 CAD 1/15/2026 11:52:08 AM
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Req. No. 2584 Page 11Every fact on this page links to its source, starting with the official bill record.