Sec. 21.27.915. Overpayment or underpayment.

175 words·~1 min read·/ak/title-21/chapter-27/21-27-915

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

(a)When a pharmacy benefits manager conducts an audit of a pharmacy, the pharmacy benefits manager shall base a finding of overpayment or underpayment by the pharmacy on the actual overpayment or underpayment and not on a projection based on the number of patients served having a similar diagnosis or on the number of similar orders or refills for similar drugs, except as provided in

(b)of this section.

(b)A pharmacy benefits manager may resolve a finding of overpayment or underpayment by entering into a settlement agreement with the pharmacy. The settlement agreement

(1)must comply with the requirements of AS 21.36.125 ; and

(2)may be based on a statistically justifiable projection method.

(c)A pharmacy benefits manager may not include the dispensing fee amount in a finding of an overpayment unless

(1)a prescription was not actually dispensed;

(2)the prescriber denied authorization;

(3)the prescription dispensed was a medication error by the pharmacy; or

(4)the identified overpayment is solely based on an extra dispensing fee.