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1 STATE OF OKLAHOMA
1
2 1st Session of the 60th Legislature (2025)
2
3 SENATE BILL 993 By: Gollihare
3
4
4
5
5
6 AS INTRODUCED
6
7 An Act relating to pharmacy benefit managers;
7 amending 59 O.S. 2021, Sections 356.1, 356.2, 356.3,
8 as amended by Sections 1, 2, and 3, Chapter 332,
8 O.S.L. 2024, and 356.4 (59 O.S. Supp. 2024, Sections
9 356.1, 356.2, and 356.3), which relate to
9 definitions, pharmacy audit requirements, appeals
10 process, and prohibited extrapolation audit;
10 modifying notice contents; prohibiting assessment of
11 certain fines under certain circumstances; expanding
11 certain claim limits; establishing requirements for
12 preliminary audit findings reports; requiring
12 provision of certain final audit results within a
13 certain time period; updating statutory reference;
13 requiring certain notification to Attorney General in
14 certain circumstances; expanding requirement for
14 initiation of certain audit; lengthening time period
15 for certain preliminary report; allowing certain
15 extension request; shortening certain time period for
16 certain final report; establishing requirements for
16 audit findings report; modifying definition; defining
17 terms; requiring certain tolling in certain declared
17 disaster; providing certain exceptions; amending 59
18 O.S. 2021, Sections 357 and 358, as amended by
18 Sections 4 and 5, Chapter 332, O.S.L. 2024 (59 O.S.
19 Supp. 2024, Sections 357 and 358), which relate to
19 definitions and pharmacy benefits management
20 licensure; defining terms; updating statutory
20 references; requiring certain time period of tolling
21 in certain declared disaster; establishing certain
21 filing period after lifting of disaster declaration;
22 prohibiting certain denials; and declaring an
22 emergency.
23
23
24
24
Req. No. 698 Page 1
1
1
2 BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
2
3 SECTION 1. AMENDATORY 59 O.S. 2021, Section 356.1, as
3
4 amended by Section 1, Chapter 332, O.S.L. 2024 (59 O.S. Supp. 2024,
4
5 Section 356.1), is amended to read as follows:
5
6 Section 356.1. A. For purposes of the Pharmacy Audit Integrity
6
7 Act, "pharmacy benefits manager":
7
8 1. "Pharmacy benefits manager" or "PBM" shall have the same
8
9 meaning as in Section 6960 of Title 36 of the Oklahoma Statutes;
9
10 2. "Audit" means any review, inspection, or analysis conducted
10
11 by a PBM or its representative of a pharmacy's records, practices,
11
12 or compliance with contractual obligations; and
12
13 3. "Disaster declaration" and "declared disaster" means a
13
14 declaration issued by the Governor of this state or the President of
14
15 the United States for an event that qualifies as a disaster
15
16 including, but not limited to, floods, tornadoes, earthquakes,
16
17 wildfires, terrorist attacks, or other catastrophic events.
17
18 B. The purpose of the Pharmacy Audit Integrity Act is to
18
19 establish minimum and uniform standards and criteria for the audit
19
20 of pharmacy records by or on behalf of certain entities.
20
21 C. The Pharmacy Audit Integrity Act shall apply to any audit of
21
22 the records of a pharmacy conducted by a managed care company,
22
23 nonprofit hospital, medical service organization, insurance company,
23
24 third-party payor, pharmacy benefits manager, a health program
24
Req. No. 698 Page 2
1 administered by a department of this state, or any entity that
1
2 represents these companies, groups, or departments.
2
3 D. The Attorney General may promulgate rules to implement the
3
4 provisions of the Pharmacy Audit Integrity Act.
4
5 SECTION 2. AMENDATORY 59 O.S. 2021, Section 356.2, as
5
6 amended by Section 2, Chapter 332, O.S.L. 2024 (59 O.S. Supp. 2024,
6
7 Section 356.2), is amended to read as follows:
7
8 Section 356.2. A. The entity conducting an audit of a pharmacy
8
9 shall:
9
10 1. Identify and specifically describe the audit and appeal
10
11 procedures in the pharmacy contract. Prescription claim
11
12 documentation and record-keeping requirements shall not exceed the
12
13 requirements set forth by the Oklahoma Pharmacy Act or other
13
14 applicable state or federal laws or regulations;
14
15 2. Give the pharmacy written notice by certified letter to the
15
16 pharmacy and the pharmacy's contracting agent, including
16
17 identification of specific prescription numbers and, fill dates,
17
18 drug name, and National Drug Code (NDC) number to be audited, at
18
19 least fourteen (14) calendar days prior to conducting the audit,
19
20 including, but not limited to, an on-site audit, a desk audit, or a
20
21 wholesale purchase audit, request for documentation related to the
21
22 dispensing of a prescription drug or any reimbursed activity by a
22
23 pharmacy provider; provided, however, that wholesale purchase audits
23
24 shall require a minimum of thirty (30) calendar days' written
24
Req. No. 698 Page 3
1 notice. For an on-site audit, the audit date shall be the date the
1
2 on-site audit occurs. For all other audit types, the audit date
2
3 shall be the date the pharmacy provides the documentation requested
3
4 in the audit notice. The pharmacy shall have the opportunity to
4
5 reschedule the audit no more than seven (7) calendar days from the
5
6 date designated on the original audit notification;
6
7 3. Not interfere with the delivery of pharmacist services to a
7
8 patient and shall utilize every reasonable effort to minimize
8
9 inconvenience and disruption to pharmacy operations during the audit
9
10 process;
10
11 4. Conduct any audit involving clinical or professional
11
12 judgment by means of or in consultation with a licensed pharmacist;
12
13 5. Not consider as fraud any clerical or record-keeping error,
13
14 such as a typographical error, scrivener's error or computer error,
14
15 including, but not limited to, a miscalculated day supply,
15
16 incorrectly billed prescription written date or prescription origin
16
17 code, and such errors shall not be subject to recoupment. The
17
18 pharmacy shall have the right to submit amended claims
18
19 electronically to correct clerical or record-keeping errors in lieu
19
20 of recoupment. To the extent that an audit results in the
20
21 identification of any clerical or record-keeping errors such as
21
22 typographical errors, scrivener's errors or computer errors in a
22
23 required document or record, the pharmacy shall not be subject to
23
24 recoupment of funds by the pharmacy benefits manager unless the
24
Req. No. 698 Page 4
1 pharmacy benefits manager can provide proof of intent to commit
1
2 fraud. A person shall not be subject to criminal penalties for
2
3 errors provided for in this paragraph without proof of intent to
3
4 commit fraud;
4
5 6. Permit a pharmacy to use the records of a hospital,
5
6 physician, or other authorized practitioner of the healing arts for
6
7 drugs or medicinal supplies written or transmitted by any means of
7
8 communication for purposes of validating the pharmacy record with
8
9 respect to orders or refills of a legend or narcotic drug;
9
10 7. Not include the dispensing fee amount or the actual invoice
10
11 cost of the prescription dispensed in a finding of an audit
11
12 recoupment unless a prescription was not actually dispensed or a
12
13 physician denied authorization of a dispensing order;
13
14 8. Audit each pharmacy under identical standards, regularity
14
15 and parameters as other similarly situated pharmacies and all
15
16 pharmacies owned or managed by the pharmacy benefits manager
16
17 conducting or having conducted the audit;
17
18 9. Not exceed one (1) year from the date the claim was
18
19 submitted to or adjudicated by a managed care company, nonprofit
19
20 hospital or medical service organization, insurance company, third-
20
21 party payor, pharmacy benefits manager, a health program
21
22 administered by a department of this state, or any entity that
22
23 represents the companies, groups, or departments for the period
23
24 covered by an audit;
24
Req. No. 698 Page 5
1 10. Not schedule or initiate an audit during the first seven
1
2 (7) calendar days of any month unless otherwise consented to by the
2
3 pharmacy;
3
4 11. Disclose to any plan sponsor whose claims were included in
4
5 the audit any money recouped in the audit;
5
6 12. Not require pharmacists to break open packaging labeled
6
7 "for single-patient-use only". Packaging labeled "for single-
7
8 patient-use only" shall be deemed to be the smallest package size
8
9 available; and
9
10 13. Upon recoupment of funds from a pharmacy, refund first to
10
11 the patient the portion of the recovered funds that were originally
11
12 paid by the patient, provided such funds were part of the
12
13 recoupment; and
13
14 14. Not assess a fine, penalty, or any other financial
14
15 requirement on the pharmacy or pharmacist for any prescription
15
16 audited unless there is a valid recoupment under the Pharmacy Audit
16
17 Integrity Act.
17
18 B. 1. Any entity that conducts wholesale purchase review
18
19 during an audit of a pharmacist or pharmacy shall not require the
19
20 pharmacist or pharmacy to provide a full dispensing report.
20
21 Wholesaler invoice reviews shall be limited to verification of
21
22 purchase inventory specific to the pharmacy claims paid by the
22
23 health benefits plan or pharmacy benefits manager conducting the
23
24 audit.
24
Req. No. 698 Page 6
1 2. Any entity conducting an audit shall not identify or label a
1
2 prescription claim as an audit discrepancy when:
2
3 a. the National Drug Code for the dispensed drug is in a
3
4 quantity that is a subunit or multiple of the drug
4
5 purchased by the pharmacist or pharmacy as supported
5
6 by a wholesale invoice,
6
7 b. the pharmacist or pharmacy dispensed the correct
7
8 quantity of the drug according to the prescription,
8
9 and
9
10 c. the drug dispensed by the pharmacist or pharmacy
10
11 shares all but the last two digits of the National
11
12 Drug Code of the drug reflected on the supplier
12
13 invoice.
13
14 3. An entity conducting an audit shall accept as evidence,
14
15 subject to validation, to support the validity of a pharmacy claim
15
16 related to a dispensed drug:
16
17 a. redacted copies of supplier invoices in the
17
18 pharmacist's or pharmacy's possession, or
18
19 b. invoices and any supporting documents from any
19
20 supplier as authorized by federal or state law to
20
21 transfer ownership of the drug acquired by the
21
22 pharmacist or pharmacy.
22
23 4. An entity conducting an audit shall provide, no later than
23
24 five (5) calendar days after the date of a request by the pharmacist
24
Req. No. 698 Page 7
1 or pharmacy, all supporting documents the pharmacist's or pharmacy's
1
2 purchase suppliers provided to the health benefits plan issuer or
2
3 pharmacy benefits manager.
3
4 C. A pharmacy shall be allowed to provide the pharmacy's
4
5 computerized patterned medical records or the records of a hospital,
5
6 physician, or other authorized practitioner of the healing arts for
6
7 drugs or medicinal supplies written or transmitted by any means of
7
8 communication for purposes of supporting the pharmacy record with
8
9 respect to orders or refills of a legend or narcotic drug.
9
10 D. The entity conducting the audit shall not audit more than
10
11 fifty prescriptions, with specific date of service, per calendar
11
12 year. The PBM or its agent shall not exceed an annual limit of one
12
13 hundred prescription claims with a specific prescription number and
13
14 date of fill per calendar year. The annual limit to the number of
14
15 prescription claims audited shall be inclusive of all audits by a
15
16 PBM or its agent, including any prescription-related documentation
16
17 requests from the health insurer, pharmacy benefits manager or any
17
18 third-party company conducting audits on behalf of any health
18
19 insurer or pharmacy benefits manager during a calendar year.
19
20 E. If paper copies of records are requested by the entity
20
21 conducting the audit, the entity shall pay twenty-five cents ($0.25)
21
22 per page to cover the costs incurred by the pharmacy. The entity
22
23 conducting the audit shall provide the pharmacy with accurate
23
24
24
Req. No. 698 Page 8
1 instructions, including any required form for obtaining
1
2 reimbursement for the copied records.
2
3 F. The entity conducting the audit shall:
3
4 1. Deliver a preliminary audit findings report to the pharmacy
4
5 and the pharmacy's contracting agent within forty-five (45) calendar
5
6 days of conducting the audit;
6
7 2. Allow the pharmacy at least ninety (90) calendar days
7
8 following receipt of the preliminary audit findings report in which
8
9 to produce documentation to address any discrepancy found during the
9
10 audit; provided, however, a pharmacy may request an extension, not
10
11 to exceed an additional forty-five (45) calendar days;
11
12 3. Deliver a final audit findings report to the pharmacy and
12
13 the pharmacy's contracting agent signed by the auditor within ten
13
14 (10) calendar days after receipt of additional documentation
14
15 provided by the pharmacy, as provided for in Section 356.3 of this
15
16 title;
16
17 4. Allow the pharmacy to reverse and resubmit claims
17
18 electronically within thirty (30) calendar days of receipt of the
18
19 final audit report in lieu of the auditing entity recouping
19
20 discrepant claim amounts from the pharmacy;
20
21 5. Not recoup any disputed funds until after final disposition
21
22 of the audit findings, including the appeals process as provided for
22
23 in Section 356.3 of this title; and
23
24 6. Not accrue interest during the audit and appeal period;
24
Req. No. 698 Page 9
1 7. Ensure that each preliminary audit findings report required
1
2 by this section includes:
2
3 a. specific prescription numbers, fill dates, drug names,
3
4 and NDC numbers, and
4
5 b. the date of receipt of documents from the pharmacy,
5
6 the pharmacy's contracting agent, or any other source
6
7 associated with the audit.
7
8 G. Each entity conducting an audit shall provide a copy of the
8
9 final audit results, and a final audit report upon request, after
9
10 completion of any review process to the plan sponsor
10
11 In addition to the requirements for a preliminary audit findings
11
12 report in this paragraph, the final audit findings report shall
12
13 include any additional documentation that was submitted to the
13
14 auditing entity;
14
15 8. Provide the plan sponsor a copy of the final audit results
15
16 within thirty (30) calendar days of the final disposition of the
16
17 audit; and
17
18 9. At the request of the plan sponsor, provide a copy of the
18
19 final audit report within thirty (30) calendar days of the request.
19
20 H. G. 1. The full amount of any recoupment on an audit shall
20
21 be refunded to the plan sponsor. Except as provided for in
21
22 paragraph 2 of this subsection, a charge or assessment for an audit
22
23 shall not be based, directly or indirectly, on amounts recouped.
23
24
24
Req. No. 698 Page 10
1 2. This subsection does not prevent the entity conducting the
1
2 audit from charging or assessing the responsible party, directly or
2
3 indirectly, based on amounts recouped if both of the following
3
4 conditions are met:
4
5 a. the plan sponsor and the entity conducting the audit
5
6 have a contract that explicitly states the percentage
6
7 charge or assessment to the plan sponsor, and
7
8 b. a commission to an agent or employee of the entity
8
9 conducting the audit is not based, directly or
9
10 indirectly, on amounts recouped.
10
11 I. H. Unless superseded by state or federal law, auditors shall
11
12 only have access to previous audit reports on a particular pharmacy
12
13 conducted by the auditing entity for the same pharmacy benefits
13
14 manager, health plan or insurer. An auditing vendor contracting
14
15 with multiple pharmacy benefits managers or health insurance plans
15
16 shall not use audit reports or other information gained from an
16
17 audit on a pharmacy to conduct another audit for a different
17
18 pharmacy benefits manager or health insurance plan.
18
19 J. Sections A through I
19
20 I. Paragraph 2 of subsection A of this section through
20
21 subsection D of this section, and paragraph 1 through paragraph 7 of
21
22 subsection F of this section shall not apply to any audit initiated
22
23 based on or that involves suspicion of fraud, willful
23
24 misrepresentation, or abuse.
24
Req. No. 698 Page 11
1 K. J. If the Attorney General, after notice and opportunity for
1
2 hearing, finds that the entity conducting the audit failed to follow
2
3 any of the requirements pursuant to the Pharmacy Audit Integrity
3
4 Act, the audit shall be considered null and void. Any monies
4
5 recouped from a null and void audit shall be returned to the
5
6 affected pharmacy within fourteen (14) calendar days. Any violation
6
7 of this section by a pharmacy benefits manager or auditing entity
7
8 shall be deemed a violation of the Pharmacy Audit Integrity Act.
8
9 SECTION 3. AMENDATORY 59 O.S. 2021, Section 356.3, as
9
10 amended by Section 3, Chapter 332, O.S.L. 2024 (59 O.S. Supp. 2024,
10
11 Section 356.3), is amended to read as follows:
11
12 Section 356.3. A. Each entity conducting an audit shall
12
13 establish a written appeals process under which a pharmacy may
13
14 appeal an unfavorable preliminary audit report and/or final audit
14
15 report to the entity.
15
16 B. Following an appeal, if the entity finds that an unfavorable
16
17 audit report or any portion thereof is unsubstantiated, the entity
17
18 shall dismiss the audit report or the unsubstantiated portion of the
18
19 audit report without any further action.
19
20 C. Any final audit report, following the final audit appeal
20
21 period, with a finding of fraud or willful misrepresentation shall
21
22 be referred to the district attorney having proper jurisdiction or
22
23 the Attorney General for prosecution upon completion of the appeals
23
24 process. If a finding of fraud, willful misrepresentation, or abuse
24
Req. No. 698 Page 12
1 is referred to a district attorney under this subsection, the
1
2 auditing entity shall notify the Attorney General to whom the
2
3 referral was made and the date the referral was made.
3
4 D. For any audit initiated based on or that involves suspicion
4
5 of fraud, willful misrepresentation, or abuse, the auditing entity
5
6 shall provide, in writing, at the time of the audit, a clear and
6
7 conspicuous declaration to the pharmacy being audited that the audit
7
8 is being conducted under suspicion of fraud, willful
8
9 misrepresentation, or abuse and a statement of facts that supports
9
10 the reasonable suspicion.
10
11 E. Any entity conducting an audit that is based on or involves
11
12 suspicion of fraud, willful misrepresentation, or abuse shall
12
13 provide to the Office of the Attorney General:
13
14 1. Notice at least two (2) calendar days prior to beginning
14
15 performance of an audit pursuant to this section;
15
16 2. A preliminary report within thirty (30) ninety (90) calendar
16
17 days of performing notification of the audit to the pharmacy and the
17
18 pharmacy's contracting agent pursuant to this section. The auditing
18
19 entity may request an extension from the Attorney General, not to
19
20 exceed an additional thirty (30) calendar days; and
20
21 3. A final report within thirty (30) ten (10) calendar days
21
22 following the closure of the final appeal period for an audit
22
23 performed pursuant to this section. The auditing entity may request
23
24
24
Req. No. 698 Page 13
1 an extension from the Attorney General, not to exceed an additional
1
2 ten (10) calendar days.
2
3 F. 1. The preliminary audit findings report required by
3
4 subsection E of this section shall include:
4
5 a. specific prescription numbers, fill dates, drug names,
5
6 and National Drug Code (NDC) numbers which were part
6
7 of the audit, and
7
8 b. the dates when documents were received by the auditing
8
9 entity from the pharmacy, the pharmacy's contracting
9
10 agent, or any other source associated with the audit.
10
11 2. In addition to the requirements for a preliminary audit
11
12 findings report pursuant to this subsection, the final audit
12
13 findings report shall include any additional documentation that was
13
14 submitted to the auditing entity.
14
15 G. The Attorney General, authorized employees, and examiners
15
16 shall have access to any pharmacy benefits manager's files and
16
17 records that may relate to an audit that is based on or involves
17
18 suspicion of fraud, willful misrepresentation, or abuse.
18
19 G. H. The Attorney General may levy a civil or administrative
19
20 fine of not less than One Hundred Dollars ($100.00) and not greater
20
21 than Ten Thousand Dollars ($10,000.00) for each violation of this
21
22 section and assess any other penalty or remedy authorized by law.
22
23 SECTION 4. AMENDATORY 59 O.S. 2021, Section 356.4, is
23
24 amended to read as follows:
24
Req. No. 698 Page 14
1 Section 356.4. A. For the purposes of the Pharmacy Audit
1
2 Integrity Act, "extrapolation audit" means an audit of a sample of
2
3 prescription drug benefit claims submitted by a pharmacy to the
3
4 entity conducting the audit that is then used to estimate audit
4
5 results for a larger batch or group of claims not reviewed by the
5
6 auditor, including refills not listed in the written notification in
6
7 accordance with paragraph 2 of subsection A of Section 356.2 of this
7
8 title.
8
9 B. The entity conducting the audit shall not use the accounting
9
10 practice of extrapolation in calculating recoupments or penalties
10
11 for audits.
11
12 SECTION 5. NEW LAW A new section of law to be codified
12
13 in the Oklahoma Statutes as Section 356.6 of Title 59, unless there
13
14 is created a duplication in numbering, reads as follows:
14
15 A. Notwithstanding any other provision of law, the ability of a
15
16 pharmacy benefits manager (PBM) to initiate, continue, or conclude
16
17 an audit of a pharmacy shall be tolled for the duration of a
17
18 declared disaster and for an additional period of thirty (30)
18
19 calendar days following the termination of a declared disaster.
19
20 This shall apply only to the pharmacies located within the
20
21 geographical boundaries of the county or counties affected by the
21
22 declared disaster.
22
23
23
24
24
Req. No. 698 Page 15
1 B. The provisions of this section shall apply to all PBMs
1
2 operating with within this state, and to all audits conducted
2
3 pursuant to contracts between PBMs and pharmacies.
3
4 C. This section shall not apply to:
4
5 1. Audits conducted for suspected fraudulent activity if
5
6 documented evidence of such activity exists; or
6
7 2. Audits required to comply with federal or state law
7
8 unrelated to the contractual relationship between a PBM and a
8
9 pharmacy.
9
10 D. Nothing in this section shall be construed to prohibit a
10
11 pharmacy from voluntarily agreeing to continue or complete an audit
11
12 during the tolling period, provided such agreement is documented in
12
13 writing and signed by both parties.
13
14 SECTION 6. AMENDATORY 59 O.S. 2021, Section 357, as
14
15 amended by Section 4, Chapter 332, O.S.L. 2024 (59 O.S. Supp. 2024,
15
16 Section 357), is amended to read as follows:
16
17 Section 357. A. As used in Sections 357 through 360 of this
17
18 title and Section 8 of this act:
18
19 1. "Covered entity" means a nonprofit hospital or medical
19
20 service organization, for-profit hospital or medical service
20
21 organization, insurer, health benefit plan, health maintenance
21
22 organization, health program administered by the state in the
22
23 capacity of providing health coverage, or an employer, labor union,
23
24 or other group of persons that provides health coverage to persons
24
Req. No. 698 Page 16
1 in this state. This term does not include a health benefit plan
1
2 that provides coverage only for accidental injury, specified
2
3 disease, hospital indemnity, disability income, or other limited
3
4 benefit health insurance policies and contracts that do not include
4
5 prescription drug coverage;
5
6 2. "Covered individual" means a member, participant, enrollee,
6
7 contract holder or policy holder or beneficiary of a covered entity
7
8 who is provided health coverage by the covered entity. A covered
8
9 individual includes any dependent or other person provided health
9
10 coverage through a policy, contract or plan for a covered
10
11 individual;
11
12 3. "Department" means the Insurance Department;
12
13 4. "Maximum allowable cost", "MAC", or "MAC list" means the
13
14 list of drug products delineating the maximum per-unit reimbursement
14
15 for multiple-source prescription drugs, medical product, or device;
15
16 5. "Multisource drug product reimbursement" (reimbursement)
16
17 means the total amount paid to a pharmacy inclusive of any reduction
17
18 in payment to the pharmacy, excluding prescription dispense fees;
18
19 6. "Office" means the Office of the Attorney General;
19
20 7. "Pharmacy benefits management" means a service provided to
20
21 covered entities to facilitate the provision of prescription drug
21
22 benefits to covered individuals within the state, including
22
23 negotiating pricing and other terms with drug manufacturers and
23
24
24
Req. No. 698 Page 17
1 providers. Pharmacy benefits management may include any or all of
1
2 the following services:
2
3 a. claims processing, retail network management and
3
4 payment of claims to pharmacies for prescription drugs
4
5 dispensed to covered individuals,
5
6 b. clinical formulary development and management
6
7 services, or
7
8 c. rebate contracting and administration;
8
9 8. "Pharmacy benefits manager" or "PBM" means a person,
9
10 business, or other entity that performs pharmacy benefits
10
11 management. The term shall include a person or entity acting on
11
12 behalf of a PBM in a contractual or employment relationship in the
12
13 performance of pharmacy benefits management for a managed care
13
14 company, nonprofit hospital, medical service organization, insurance
14
15 company, third-party payor, or a health program administered by an
15
16 agency or department of this state;
16
17 9. "Plan sponsor" means the employers, insurance companies,
17
18 unions and health maintenance organizations or any other entity
18
19 responsible for establishing, maintaining, or administering a health
19
20 benefit plan on behalf of covered individuals; and
20
21 10. "Provider" means a pharmacy licensed by the State Board of
21
22 Pharmacy, or an agent or representative of a pharmacy, including,
22
23 but not limited to, the pharmacy's contracting agent, which
23
24 dispenses prescription drugs or devices to covered individuals.
24
Req. No. 698 Page 18
1 B. Nothing in the definition of pharmacy benefits management or
1
2 pharmacy benefits manager in the Patient's Right to Pharmacy Choice
2
3 Act, Pharmacy Audit Integrity Act, or Sections 357 through 360 of
3
4 this title and Section 8 of this act shall deem an employer a
4
5 "pharmacy benefits manager" of its own self-funded health benefit
5
6 plan, except, to the extent permitted by applicable law, where the
6
7 employer, without the utilization of a third party and unrelated to
7
8 the employer's own pharmacy:
8
9 a. negotiates
9
10 1. Negotiates directly with drug manufacturers,;
10
11 b. processes
11
12 2. Processes claims on behalf of its members,; or
12
13 c. manages
13
14 3. Manages its own retail network of pharmacies.
14
15 SECTION 7. AMENDATORY 59 O.S. 2021, Section 358, as
15
16 amended by Section 5, Chapter 332, O.S.L. 2024 (59 O.S. Supp. 2024,
16
17 Section 358), is amended to read as follows:
17
18 Section 358. A. In order to provide pharmacy benefits
18
19 management or any of the services included under the definition of
19
20 pharmacy benefits management in this state, a pharmacy benefits
20
21 manager or any entity acting as one in a contractual or employment
21
22 relationship for a covered entity shall first obtain a license from
22
23 the Insurance Department, and the Department may charge a fee for
23
24 such licensure.
24
Req. No. 698 Page 19
1 B. The Department shall establish, by regulation, licensure
1
2 procedures, required disclosures for pharmacy benefits managers
2
3 (PBMs) and other rules as may be necessary for carrying out and
3
4 enforcing the provisions of this title. The licensure procedures
4
5 shall, at a minimum, include the completion of an application form
5
6 that shall include the name and address of an agent for service of
6
7 process, the payment of a requisite fee, and evidence of the
7
8 procurement of a surety bond.
8
9 C. The Department or the Office of the Attorney General may
9
10 subpoena witnesses and information. Its compliance officers may
10
11 take and copy records for investigative use and prosecutions.
11
12 Nothing in this subsection shall limit the Office of the Attorney
12
13 General from using its investigative demand authority to investigate
13
14 and prosecute violations of the law.
14
15 D. The Department may suspend, revoke or refuse to issue or
15
16 renew a license for noncompliance with any of the provisions hereby
16
17 established or with the rules promulgated by the Department; for
17
18 conduct likely to mislead, deceive or defraud the public or the
18
19 Department; for unfair or deceptive business practices or for
19
20 nonpayment of an application or renewal fee or fine. The Department
20
21 may also levy administrative fines for each count of which a PBM has
21
22 been convicted in a Department hearing.
22
23 E. 1. The Office of the Attorney General, after notice and
23
24 opportunity for hearing, may instruct the Insurance Commissioner
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Req. No. 698 Page 20
1 that the PBM's license be censured, suspended, or revoked for
1
2 conduct likely to mislead, deceive, or defraud the public or the
2
3 State of Oklahoma; or for unfair or deceptive business practices, or
3
4 for any violation of the Patient's Right to Pharmacy Choice Act, the
4
5 Pharmacy Audit Integrity Act, or Sections 357 through 360 of this
5
6 title. The Office of the Attorney General may also levy
6
7 administrative fines for each count of which a PBM has been
7
8 convicted following a hearing before the Attorney General. If the
8
9 Attorney General makes such instruction, the Commissioner shall
9
10 enforce the instructed action within thirty (30) calendar days.
10
11 2. In addition to or in lieu of any censure, suspension, or
11
12 revocation of a license by the Commissioner, the Attorney General
12
13 may levy a civil or administrative fine of not less than One Hundred
13
14 Dollars ($100.00) and not greater than Ten Thousand Dollars
14
15 ($10,000.00) for each violation of this subsection and/or assess any
15
16 other penalty or remedy authorized by this section. For purposes of
16
17 this section, each day a PBM fails to comply with an investigation
17
18 or inquiry may be considered a separate violation.
18
19 F. The Attorney General may promulgate rules to implement the
19
20 provisions of Sections 357 through 360 of this title and Section 8
20
21 of this act.
21
22 SECTION 8. NEW LAW A new section of law to be codified
22
23 in the Oklahoma Statutes as Section 360.1 of Title 59, unless there
23
24 is created a duplication in numbering, reads as follows:
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Req. No. 698 Page 21
1 A. If a disaster declaration is issued for a county in this
1
2 state, the time period for a provider, a provider's representative,
2
3 or a pharmacy service administrative organization to file a below-
3
4 cost reimbursement appeal pursuant to Section 360 of Title 59 of the
4
5 Oklahoma Statutes shall be tolled for the duration of the disaster
5
6 declaration.
6
7 B. Upon the expiration of the disaster declaration, the tolling
7
8 of the filing period for below-cost reimbursement appeals shall
8
9 continue for an additional thirty (30) calendar days. Afterward,
9
10 the time period for filing a below-cost reimbursement appeal, as
10
11 otherwise provided under state law, shall resume.
11
12 C. The tolling provisions of this section shall apply only to
12
13 continuing counties included in the declared disaster area and to
13
14 below-cost reimbursement appeals arising from claims impacted during
14
15 the time period of the declared disaster.
15
16 D. A pharmacy benefits manager (PBM) shall not deny a below-
16
17 cost reimbursement appeal on timeliness if such appeal is filed
17
18 during the tolled period provided in this section.
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19 SECTION 9. It being immediately necessary for the preservation
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20 of the public peace, health or safety, an emergency is hereby
20
21 declared to exist, by reason whereof this act shall take effect and
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22 be in full force from and after its passage and approval.
22
23
23
24 60-1-698 CAD 1/19/2025 5:47:24 AM
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Req. No. 698 Page 22Every fact on this page links to its source, starting with the official bill record.