KPhA along with its pharmacy partners is proud to announce that SB117 is finally in effect. As of October 24, 2017 the Kentucky Department of Insurance (DOI) regulation describing the requirements of the maximum allowable (MAC) appeals process, the MAC list requirements and notification requirements for a granted appeal (806 KAR 17:575).
Now pharmacies have the ability to file complaints for regulatory violations and for statutory violations.
The Kentucky Department of Insurance wants to hear from you. If you notice that the PBMs are not following any of the legal processes required in SB 117, please file a complaint with DOI and they will make sure the PBM follows the process.
Also, when filing a complaint it is very important to provide documentation that the PBM received the apeal and documentation of the PBMs response to the appeal.
If you have any questions, please contact Shannon Stiglitz.
Steps to File a MAC Appeal: Each PBM licensed in Kentucky must establish a maximum allowable cost appeals process to resolve disputes over PBM reimbursements of generic drugs.
Once the appeal has been filed the PBM has 10 calendar days to respond to the appeal. The clock starts once the PBM receives the appeal. If you request for your PSAO to file an appeal the 10-day clock regarding the PBM's response will not start until the PBM receives the appeal from your PSAO.
The PBM must send a notification to the party who submitted the appeal. The notification must include the name and contact information of the persons who can answer questions about the appeal or appeals process.
iii. Next, they must individually notify all contracted pharmacies that an appeal has been granted and that they have the right to reverse and resubmit the claim.
2. The notification can be posted in a PBM's web portal, but if they use a web portal they must send individual notification via e-mail to the contracted pharmacy with a hyperlink to the granted appeal.
The Kentucky licensed wholesaler offering the drug at or below maximum allowable cost on the date of fill.
d. Are they making the change in the MAC in cases of granted appeals?
b. Are you being reimbursed below NADAC because they are using drugs that are temporarily unavailable, obsolete or on a drug shortage list to calculated?
b. KRS 304.17A-578 Substantial contract changes must be sent 90 days in advance and in an orange envelope. "material change" means anything that impacts, reimbursement, has a significant administrative burden, or changes the contract or provider network.
Appropriate insurance plan insurance plan or claims information.
3. Follow directions to submit the form.
4. If you have questions and concerns, contact KPhA for assistance.
KPhA launches Ambassador Program - interested members should contact Mark Glasper.