The bill amends the Pharmacy Audit Integrity Act to improve the auditing process conducted by pharmacy benefits managers (PBMs) and enhance protections for pharmacies. Key changes include the introduction of specific definitions related to audits and PBMs, as well as new requirements for audit procedures. Pharmacies must receive written notice prior to audits, and certain fines are prohibited unless there is a valid recoupment. Audits are limited to one year from the claim submission date, and preliminary audit findings must be reported within 45 days, with final reports due within 10 days after receiving additional documentation. The bill also allows pharmacies to correct clerical errors without facing recoupment and mandates uniformity in audit practices across similar pharmacies.

Additionally, the bill establishes new provisions for PBMs, including the requirement to obtain a license from the Insurance Department and to notify the Attorney General of any referrals for prosecution related to audits. It prohibits the use of extrapolation for calculating recoupments or penalties and tolls the ability of PBMs to initiate audits during declared disasters and for 30 days afterward, with exceptions for suspected fraud. The legislation also aims to enhance the transparency of the Maximum Allowable Cost (MAC) pricing system by requiring regular updates and ensuring that drugs on the MAC list meet specific FDA criteria. It establishes a streamlined appeals process for pharmacies contesting reimbursement amounts, ensuring timely responses from PBMs and protecting pharmacies from unfair pricing practices.

Statutes affected:
Introduced: 59-356.1, 59-356.2, 59-356.3, 59-357, 59-358
House Committee Substitute for Senate Bill: 59-356.1, 59-356.2, 59-356.3, 59-357, 59-358, 59-360
Committee Substitute: 59-356.1, 59-356.2, 59-356.3, 59-357, 59-358
Floor (House): 59-356.1, 59-356.2, 59-356.3, 59-357, 59-358, 59-360
Floor (Senate): 59-356.1, 59-356.2, 59-356.3, 59-357, 59-358
Engrossed: 59-356.1, 59-356.2, 59-356.3, 59-357, 59-358, 59-360
Amended And Engrossed: 59-356.1, 59-356.2, 59-356.3, 59-357, 59-358, 59-360
Enrolled (final version): 59-356.1, 59-356.2, 59-356.3, 59-357, 59-358, 59-360