Oklahoma § 59-360.1 - Tolling period to file a below-cost reimbursement appeal

§ 59-360.1. Tolling period to file a below-cost reimbursement appeal

during a declared disaster.

A. If a disaster declaration is issued for a county in this

state, the time period for a provider, a provider’s representative,

or a pharmacy service administrative organization to file a belowcost reimbursement appeal pursuant to Section 360 of Title 59 of the

Oklahoma Statutes shall be tolled for the duration of the disaster

declaration.

B. Upon the expiration of the disaster declaration, the tolling

of the filing period for below-cost reimbursement appeals shall

continue for an additional thirty (30) calendar days. Afterward,

the time period for filing a below-cost reimbursement appeal, as

otherwise provided under state law, shall resume.

C. The tolling provisions of this section shall apply only to

continuing counties included in the declared disaster area and to

below-cost reimbursement appeals arising from claims impacted during

the time period of the declared disaster.

D. A pharmacy benefits manager (PBM) shall not deny a belowcost reimbursement appeal on timeliness if such appeal is filed

during the tolled period provided in this section.

E. The Attorney General may promulgate rules to implement the

provisions of this act.

Added by Laws 2025, c. 300, § 9, emerg. eff. May 22, 2025.

§59-360v1. Pharmacy benefits manager – Contractual duties to

provider.

A. The pharmacy benefits manager shall, with respect to

contracts between a pharmacy benefits manager and a provider,

including a pharmacy service administrative organization:

l. Include in such contracts the specific sources utilized to

determine the maximum allowable cost (MAC) pricing of the pharmacy,

update MAC pricing at least every seven (7) calendar days, and

establish a process for providers to readily access the MAC list

specific to that provider;

2. In order to place a drug on the MAC list, ensure that the

drug is listed as “A” or “B” rated in the most recent version of the

United States Food and Drug Administration (FDA) Approved Drug

Products with Therapeutic Equivalence Evaluations, also known as the

Orange Book, and the drug is generally available for purchase by

pharmacies in the state from national or regional wholesalers and is

not obsolete;

3. Ensure dispensing fees are not included in the calculation

of MAC price reimbursement to pharmacy providers;

4. Provide a reasonable administration appeals procedure to

allow a provider, a provider’s representative and a pharmacy service

administrative organization to contest reimbursement amounts within

fourteen (14) calendar days of the final adjusted payment date. The

Oklahoma Statutes - Title 59. Professions and Occupations

pharmacy benefits manager shall not prevent the pharmacy or the

pharmacy service administrative organization from filing

reimbursement appeals in an electronic batch format. The pharmacy

benefits manager must respond to a provider, a provider’s

representative and a pharmacy service administrative organization

who have contested a reimbursement amount through this procedure

within ten (10) calendar days. The pharmacy benefits manager must

respond in an electronic batch format to reimbursement appeals filed

in an electronic batch format. The pharmacy benefits manager shall

not require a pharmacy or pharmacy services administrative

organization to log into a system to upload individual claim appeals

or to download individual appeal responses. If a price update is

warranted, the pharmacy benefits manager shall make the change in

the reimbursement amount, permit the dispensing pharmacy to reverse

and rebill the claim in question, and make the reimbursement amount

change retroactive and effective for all contracted providers;

5. If a below-cost reimbursement appeal is denied, the PBM

shall provide the reason for the denial, including the National Drug

Code (NDC) number from, and the name of, the specific national or

regional wholesalers doing business in this state where the drug is

currently in stock and available for purchase by the dispensing

pharmacy at a price below the PBM’s reimbursement price. The PBM

shall include documented proof from the specific national or

regional wholesalers doing business in this state showing that the

drug is currently in stock and available for purchase by the

dispensing pharmacy at a price below the PBM’s reimbursement price.

If the NDC number provided by the pharmacy benefits manager is not

available below the acquisition cost obtained from the

pharmaceutical wholesaler from whom the dispensing pharmacy

purchases the majority of the prescription drugs that are dispensed,

the pharmacy benefits manager shall immediately adjust the

reimbursement amount, permit the dispensing pharmacy to reverse and

rebill the claim in question, and make the reimbursement amount

adjustment retroactive and effective for all contracted providers;

6. Any appeal that results in an increase in the reimbursement

from the PBM that continues to be below the pharmacy’s acquisition

cost shall be considered a denial under this section. Any denial of

an appeal shall follow the requirements of paragraph 5 of this

subsection; and

7. The PBM shall not require a pharmacy to collect additional

monies following a successful below-cost reimbursement appeal from

any person or entity other than the PBM who adjudicated the drug

claim, including the patient or plan sponsor.

B. The reimbursement appeal requirements in this section shall

apply to all drugs, medical products, or devices reimbursed

according to any payment methodology, including, but not limited to:

Oklahoma Statutes - Title 59. Professions and Occupations

1. Average acquisition cost, including the National Average

Drug Acquisition Cost;

2. Average manufacturer price;

3. Average wholesale price;

4. Brand effective rate or generic effective rate;

5. Discount indexing;

6. Federal upper limits;

7. Wholesale acquisition cost; and

8. Any other term that a pharmacy benefits manager or an

insurer of a health benefit plan may use to establish reimbursement

rates to a pharmacist or pharmacy for pharmacist services.

C. The pharmacy benefits manager shall not place a drug on a

MAC list, unless there are at least two therapeutically equivalent,

multiple-source drugs, generally available for purchase by

dispensing retail pharmacies from national or regional wholesalers.

D. In the event that a drug is placed on the FDA Drug Shortages

Database, pharmacy benefits managers shall reimburse claims to

pharmacies at no less than the wholesale acquisition cost for the

specific NDC number being dispensed.

E. The pharmacy benefits manager shall not require

accreditation or licensing of providers, or any entity licensed or

regulated by the State Board of Pharmacy, other than by the State

Board of Pharmacy or federal government entity as a condition for

participation as a network provider.

F. A pharmacy or pharmacist may decline to provide the

pharmacist clinical or dispensing services to a patient or pharmacy

benefits manager if the pharmacy or pharmacist is to be paid less

than the pharmacy’s cost for providing the pharmacist clinical or

dispensing services.

G. The pharmacy benefits manager shall provide a dedicated

telephone number, email address and names of the personnel with

decision-making authority regarding MAC appeals and pricing.

Added by Laws 2014, c. 263, § 4, eff. July 1, 2014. Amended by Laws

2016, c. 285, § 8, eff. Nov. 1, 2016; Laws 2021, c. 409, § 5, emerg.

eff. May 4, 2021; Laws 2024, c. 332, § 6, emerg. eff. May 22, 2024;

Laws 2025, c. 300, § 8, emerg. eff. May 22, 2025.

§59-360v2. Pharmacy benefits manager – Contractual duties to

provider.

A. The pharmacy benefits manager shall, with respect to

contracts between a pharmacy benefits manager and a provider,

including a pharmacy service administrative organization:

l. Include in such contracts the specific sources utilized to

determine the maximum allowable cost (MAC) pricing of the pharmacy,

update MAC pricing at least every seven (7) calendar days, and

establish a process for providers to readily access the MAC list

specific to that provider;

Oklahoma Statutes - Title 59. Professions and Occupations

2. In order to place a drug on the MAC list, ensure that the

drug is listed as “A” or “B” rated in the most recent version of the

FDA’s Approved Drug Products with Therapeutic Equivalence

Evaluations, also known as the Orange Book, and the drug is

generally available for purchase by pharmacies in the state from

national or regional wholesalers and is not obsolete;

3. Ensure dispensing fees are not included in the calculation

of MAC price reimbursement to pharmacy providers;

4. Provide a reasonable administration appeals procedure to

allow a provider, a provider’s representative and a pharmacy service

administrative organization to contest reimbursement amounts within

fourteen (14) calendar days of the final adjusted payment date. The

pharmacy benefits manager shall not prevent the pharmacy or the

pharmacy service administrative organization from filing

reimbursement appeals in an electronic batch format. The pharmacy

benefits manager must respond to a provider, a provider’s

representative and a pharmacy service administrative organization

who have contested a reimbursement amount through this procedure

within ten (10) calendar days. The pharmacy benefits manager must

respond in an electronic batch format to reimbursement appeals filed

in an electronic batch format. The pharmacy benefits manager shall

not require a pharmacy or pharmacy services administrative

organization to log into a system to upload individual claim appeals

or to download individual appeal responses. If a price update is

warranted, the pharmacy benefits manager shall make the change in

the reimbursement amount, permit the dispensing pharmacy to reverse

and rebill the claim in question, and make the reimbursement amount

change retroactive and effective for all contracted providers; and

5. If a below-cost reimbursement appeal is denied, the PBM

shall provide the reason for the denial, including the National Drug

Code (NDC) number from, and the name of, the specific national or

regional wholesalers doing business in this state where the drug is

currently in stock and available for purchase by the dispensing

pharmacy at a price below the PBM’s reimbursement price. If the NDC

number provided by the pharmacy benefits manager is not available

below the acquisition cost obtained from the pharmaceutical

wholesaler from whom the dispensing pharmacy purchases the majority

of the prescription drugs that are dispensed, the pharmacy benefits

manager shall immediately adjust the reimbursement amount, permit

the dispensing pharmacy to reverse and rebill the claim in question,

and make the reimbursement amount adjustment retroactive and in

effect for all contracted providers for future claims billed.

B. The reimbursement appeal requirements in this section shall

apply to all drugs, medical products, or devices reimbursed

according to any payment methodology, including, but not limited to:

1. Average acquisition cost, including the National Average

Drug Acquisition Cost;

Oklahoma Statutes - Title 59. Professions and Occupations

2. Average manufacturer price;

3. Average wholesale price;

4. Brand effective rate or generic effective rate;

5. Discount indexing;

6. Federal upper limits;

7. Wholesale acquisition cost; and

8. Any other term that a pharmacy benefits manager or an

insurer of a health benefit plan may use to establish reimbursement

rates to a pharmacist or pharmacy for pharmacist services.

C. The pharmacy benefits manager shall not place a drug on a

MAC list, unless there are at least two therapeutically equivalent,

multiple-source drugs, generally available for purchase by

dispensing retail pharmacies from national or regional wholesalers.

D. In the event that a drug is placed on the FDA Drug Shortages

Database, pharmacy benefits managers shall reimburse claims to

pharmacies at no less than the wholesale acquisition cost for the

specific NDC number being dispensed.

E. The pharmacy benefits manager shall not require

accreditation or licensing of providers, or any entity licensed or

regulated by the State Board of Pharmacy, other than by the State

Board of Pharmacy or federal government entity as a condition for

participation as a network provider.

F. A pharmacy or pharmacist may decline to provide the

pharmacist clinical or dispensing services to a patient or pharmacy

benefits manager if the pharmacy or pharmacist is to be paid less

than the pharmacy’s cost for providing the pharmacist clinical or

dispensing services.

G. The pharmacy benefits manager shall provide a dedicated

telephone number, email address and names of the personnel with

decision-making authority regarding MAC appeals and pricing.

H. Any pharmacy benefits manager (PBM) that leases, rents, or

otherwise makes its provider network or contracts available to

another pharmacy benefits manager shall:

1. Provide notice to all contracted providers of the lease

arrangement and the responsibilities of each party involved; and

2. Provide contact information in each paid or rejected claim

response that notifies the provider which contract the claim is

adjudicating against, who is processing the claim, and a phone

number to address provider issues; and

3. Transmit the network reimbursement identification

information with each claim response in NCPDP field 545-2F.

I. Any pharmacy benefits manager (PBM) that leases, rents, or

otherwise makes its provider network or contracts available to

another pharmacy benefits manager shall not combine any Employee

Retirement Income Security Act (ERISA) or government plans with any

non-ERISA or nongovernment plans.

Oklahoma Statutes - Title 59. Professions and Occupations

J. 1. Effective rate contracting is hereby prohibited in all

agreements between pharmacies or contracting agents acting on behalf

of a pharmacy and a PBM or third-party payors. No PBM or thirdparty payor shall enter into any contract that establishes payment

for services or medications based on an effective rate of

reimbursement.

2. Any PBM or third-party payor found to be in violation of

this section shall be subject to penalties, including, but not

limited to, fines, revocation of licensure, or other disciplinary

actions.

K. The provisions of this section shall not be waived, voided,

or nullified by contract.

Added by Laws 2014, c. 263, § 4, eff. July 1, 2014. Amended by Laws

2016, c. 285, § 8, eff. Nov. 1, 2016; Laws 2021, c. 409, § 5, emerg.

eff. May 4, 2021; Laws 2024, c. 332, § 6, emerg. eff. May 22, 2024;

Laws 2025, c. 414, § 3, eff. Nov. 1, 2025.