1
2
3
4
5
6
7 LONG TITLE
8 General Description:
9 This bill amends and enacts provisions related to health insurance benefits.
10 Highlighted Provisions:
11 This bill:
12 ▸ defines terms;
13 ▸ requires the commissioner of the Insurance Department to assist in creating a form
14 if requested;
15 ▸ requires a health benefit plan to ensure pharmaceutical rebates are used for certain
16 purposes;
17 ▸ enacts provisions related to pharmacy network requirements for health benefit
18 plans;
19 ▸ modifies requirements related to pharmacy audits;
20 ▸ requires a pharmacy benefit manager to offer certain options to self-funded health
21 benefit plans; and
22 ▸ makes technical and conforming changes.
23 Money Appropriated in this Bill:
24 None
25 Other Special Clauses:
26 This bill provides a special effective date.
27 Utah Code Sections Affected:
28 AMENDS:
29 31A-2-212, as last amended by Laws of Utah 2020, Chapter 32
30 31A-22-643, as enacted by Laws of Utah 2014, Chapter 111
31 31A-46-102, as last amended by Laws of Utah 2020, Chapters 198, 275 and 372
32 31A-46-301, as last amended by Laws of Utah 2020, Chapter 198
33 31A-46-304, as last amended by Laws of Utah 2020, Chapter 198
34 58-17b-622, as last amended by Laws of Utah 2023, Chapter 329
35 ENACTS:
36 31A-46-311, Utah Code Annotated 1953
37 REPEALS:
38 31A-46-101, as last amended by Laws of Utah 2020, Chapter 198
39 Uncodified Material Affected:
40 ENACTS UNCODIFIED MATERIAL
41
42 Be it enacted by the Legislature of the state of Utah:
43 Section 1. Section 31A-2-212 is amended to read:
44 31A-2-212. Miscellaneous duties.
45 (1) Upon issuance of an order limiting, suspending, or revoking a person's authority to
46 do business in Utah, and when the commissioner begins a proceeding against an insurer under
47 Chapter 27a, Insurer Receivership Act, the commissioner:
48 (a) shall notify by mail the producers of the person or insurer of whom the
49 commissioner has record; and
50 (b) may publish notice of the order or proceeding in any manner the commissioner
51 considers necessary to protect the rights of the public.
52 (2) (a) When required for evidence in a legal proceeding, the commissioner shall
53 furnish a certificate of authority of a licensee to transact the business of insurance in Utah on
54 any particular date.
55 (b) The court or other officer shall receive a certificate of authority described in this
56 Subsection (2) in lieu of the commissioner's testimony.
57 (3) (a) On the request of an insurer authorized to do a surety business, the
58 commissioner shall furnish a copy of the insurer's certificate of authority to a designated public
59 officer in this state who requires that certificate of authority before accepting a bond.
60 (b) The public officer described in Subsection (3)(a) shall file the certificate of
61 authority furnished under Subsection (3)(a).
62 (c) After a certified copy of a certificate of authority is furnished to a public officer, it
63 is not necessary, while the certificate of authority remains effective, to attach a copy of it to any
64 instrument of suretyship filed with that public officer.
65 (d) Whenever the commissioner revokes the certificate of authority or begins a
66 proceeding under Chapter 27a, Insurer Receivership Act, against an insurer authorized to do a
67 surety business, the commissioner shall immediately give notice of that action to each public
68 officer who is sent a certified copy under this Subsection (3).
69 (4) (a) The commissioner shall immediately notify every judge and clerk of the courts
70 of record in the state when:
71 (i) an authorized insurer doing a surety business:
72 (A) files a petition for receivership; or
73 (B) is in receivership; or
74 (ii) the commissioner has reason to believe that the authorized insurer doing surety
75 business:
76 (A) is in financial difficulty; or
77 (B) has unreasonably failed to carry out any of the authorized insurer's contracts.
78 (b) Upon the receipt of the notice required by this Subsection (4), it is the duty of the
79 judges and clerks to notify and require a person that files with the court a bond on which the
80 authorized insurer doing surety business is surety to immediately file a new bond with a new
81 surety.
82 (5) (a) The commissioner shall require an insurer that issues, sells, renews, or offers
83 health insurance coverage in this state to comply with PPACA and administrative rules adopted
84 by the commissioner related to regulation of health benefit plans, including:
85 (i) lifetime and annual limits;
86 (ii) prohibition of rescissions;
87 (iii) coverage of preventive health services;
88 (iv) coverage for a child or dependent;
89 (v) pre-existing condition limitations;
90 (vi) insurer transparency of consumer information including plan disclosures, uniform
91 coverage documents, and standard definitions;
92 (vii) premium rate reviews;
93 (viii) essential health benefits;
94 (ix) provider choice;
95 (x) waiting periods;
96 (xi) appeals processes;
97 (xii) rating restrictions;
98 (xiii) uniform applications and notice provisions;
99 (xiv) certification and regulation of qualified health plans; and
100 (xv) network adequacy standards.
101 (b) The commissioner shall preserve state control over:
102 (i) the health insurance market in the state;
103 (ii) qualified health plans offered in the state; and
104 (iii) the conduct of navigators, producers, and in-person assisters operating in the state.
105 (6) If requested by an association that represents pharmacies or pharmacists, the
106 commissioner shall assist the association in developing a form that outlines a pharmacy's rights
107 under state and federal law related to pharmacy benefits, pharmacy benefit managers, and
108 health benefit plans.
109 Section 2. Section 31A-22-643 is amended to read:
110 31A-22-643. Prescription synchronization -- Copay and dispensing fee
111 restrictions -- Rebate requirements -- Pharmacy networks.
112 (1) For purposes of this section:
113 (a) "Administrative fee" means the same as that term is defined in Section 31A-46-102.
114 (b) "Administrative fee excess" means the same as that term is defined in Section
115 31A-46-102.
116 (c) "Copay" means the copay normally charged for a prescription drug.
117 [
118 [
119 network of pharmacy providers.
120 (f) "Pharmacy benefit manager" means the same as that term is defined in Section
121 31A-46-102.
122 [
123 58-17b-102, that is prescribed for a chronic condition.
124 (h) "Rebate" means the same as that term is defined in Section 31A-46-102.
125 (i) "Standard rebate amount" means a rebate amount that:
126 (i) is estimated and set by a health benefit plan or the health benefit plan's pharmacy
127 benefit manager for a drug product;
128 (ii) adjusts each quarter based on rebate underpayments or overpayments; and
129 (iii) is applied when the drug product is purchased.
130 (2) A health insurance plan may not charge an amount in excess of the copay for the
131 dispensing of a prescription drug in a quantity less than the prescribed amount if:
132 (a) the pharmacy dispenses the prescription drug in accordance with the health insurer's
133 synchronization policy; and
134 (b) the prescription drug is dispensed by a network pharmacy.
135 (3) A health insurance plan that includes a prescription drug benefit:
136 (a) shall implement a synchronization policy for the dispensing of prescription drugs to
137 the plan's enrollees; and
138 (b) may not base the dispensing fee for an individual prescription on the quantity of the
139 prescription drug dispensed to fill or refill the prescription unless otherwise agreed to by the
140 plan and the contracted pharmacy at the time the individual requests synchronization.
141 (4) [
142
143 (a) A health benefit plan and the health benefit plan's pharmacy benefit manager shall
144 ensure that each pharmaceutical manufacturer rebate is used exclusively to benefit enrollees
145 using one or multiple of the following methods:
146 (i) passing down the rebate to the point of sale to offset an enrollee's deductible or
147 coinsurance;
148 (ii) using the rebate to reduce premiums paid by the enrollee;
149 (iii) using the rebate to enhance enrollee health benefits; or
150 (iv) the health benefit plan:
151 (A) when choosing among one or more prescription drugs or devices that are all
152 deemed clinically appropriate for inclusion into the health benefit plan's formulary, basing any
153 financial consideration for inclusion into the formulary exclusively on the lowest net price of a
154 prescription drug or device after accounting for available rebates, discounts, or other price
155 concessions; and
156 (B) ensuring any cost sharing obligation to the enrollee is based on the lowest net price
157 at the time the drug or device is purchased.
158 (b) When passing down a rebate as described in Subsection (4)(a)(i), a health benefit
159 plan or the health benefit plan's pharmacy benefit manager may:
160 (i) divide the rebate between the health benefit plan and the enrollee in a manner that is
161 proportional to the enrollee's payment obligation; or
162 (ii) use a standard rebate amount.
163 (5) A health benefit plan may not prohibit or condition participation in one pharmacy
164 network on participation in another pharmacy network.
165 (6) A health benefit plan and the health benefit plan's pharmacy benefit manager shall
166 use any administrative fee excess to reduce enrollee premiums.
167 (7) Subsections (4) through (6) apply to a health benefit plan renewed or entered into
168 on or after July 1, 2025.
169 Section 3. Section 31A-46-102 is amended to read:
170 31A-46-102. Definitions.
171 As used in this chapter:
172 (1) "340B drug" means a drug purchased through the 340B drug discount program by a
173 340B entity.
174 (2) "340B drug discount program" means the 340B drug discount program described in
175 42 U.S.C. Sec. 256b.
176 (3) "340B entity" means:
177 (a) an entity participating in the 340B drug discount program;
178 (b) a pharmacy of an entity participating in the 340B drug discount program; or
179 (c) a pharmacy contracting with an entity participating in the 340B drug discount
180 program to dispense drugs purchased through the 340B drug discount program.
181 (4) (a) "Administrative fee" means [
182
183 payment from a pharmaceutical manufacturer that is directly attributable to the pharmacy
184 benefit manager to invoice, collect, audit, and account for funds received from a
185 pharmaceutical manufacturer.
186 (b) "Administrative fee" does not include any administrative fee excess.
187 (5) "Administrative fee excess" means any amount of an administrative fee that
188 exceeds the direct costs of a pharmacy benefit manager to invoice, collect, audit, and account
189 for funds received from a pharmaceutical manufacturer.
190 [
191 customer's health benefit plan.
192 [
193 manager contracts to provide a pharmacy benefit management service.
194 [
195 customer's health benefit plan.
196 [
197 (9) "Direct or indirect remuneration" means any adjustment in the total compensation:
198 (a) received by a pharmacy from a pharmacy benefit manager for the sale of a drug,
199 device, or other product or service; and
200 (b) that is determined after the sale of the product or service.
201 (10) "Dispense" means the same as that term is defined in Section 58-17b-102.
202 (11) "Drug" means the same as that term is defined in Section 58-17b-102.
203 (12) "Insurer" means the same as that term is defined in Section 31A-22-636.
204 (13) "Maximum allowable cost" means:
205 (a) a maximum reimbursement amount for a group of pharmaceutically and
206 therapeutically equivalent drugs; or
207 (b) any similar reimbursement amount that is used by a pharmacy benefit manager to
208 reimburse pharmacies for multiple source drugs.
209 (14) "Medicaid program" means the same as that term is defined in Section 26B-3-101.
210 (15) "Obsolete" means a product that may be listed in national drug pricing compendia
211 but is no longer available to be dispensed based on the expiration date of the last lot
212 manufactured.
213 (16) "Patient counseling" means the same as that term is defined in Section
214 58-17b-102.
215 (17) "Pharmaceutical facility" means the same as that term is defined in Section
216 58-17b-102.
217 (18) "Pharmaceutical manufacturer" means a pharmaceutical facility that manufactures
218 prescription drugs.
219 (19) "Pharmacist" means the same as that term is defined in Section 58-17b-102.
220 (20) "Pharmacy" means the same as that term is defined in Section 58-17b-102.
221 (21) "Pharmacy benefits management service" means any of the following services
222 provided to a health benefit plan, or to a participant of a health benefit plan:
223 (a) negotiating the amount to be paid by a health benefit plan for a prescription drug; or
224 (b) administering or managing a prescription drug benefit provided by the health
225 benefit plan for the benefit of a participant of the health benefit plan, including administering
226 or managing:
227 (i) an out-of-state mail service pharmacy;
228 (ii) a specialty pharmacy;
229 (iii) claims processing;
230 (iv) payment of a claim;
231 (v) retail network management;
232 (vi) clinical formulary development;
233 (vii) clinical formulary management services;
234 (viii) rebate contracting;
235 (ix) rebate administration;
236 (x) a participant compliance program;
237 (xi) a therapeutic intervention program;
238 (xii) a disease management program; or
239 (xiii) a service that is similar to, or related to, a service described in Subsection (21)(a)
240 or [
241 (22) "Pharmacy benefit manager" means a person licensed under this chapter to
242 provide a pharmacy benefits management service.
243 (23) "Pharmacy service" means a product, good, or service provided to an individual by
244 a pharmacy or pharmacist.
245 (24) "Pharmacy services administration organization" means an entity that contracts
246 with a pharmacy to assist with third-party payer interactions and administrative services related
247 to third-party payer interactions, including:
248 (a) contracting with a pharmacy benefit manager on behalf of the pharmacy; and
249 (b) managing a pharmacy's claims payments from third-party payers.
250 (25) "Pharmacy service entity" means:
251 (a) a pharmacy services administration organization; or
252 (b) a pharmacy benefit manager.
253 (26) "Prescription device" means the same as that term is defined in Section
254 58-17b-102.
255 (27) "Prescription drug" means the same as that term is defined in Section 58-17b-102.
256 (28) (a) "Rebate" [
257
258
259 or effectiveness of a prescription drug that is paid by a manufacturer or third party, directly or
260 indirectly, to a pharmacy benefit manager or insurer after a claim has been processed and paid
261 at a pharmacy.
262 (b) "Rebate" includes an incentive, a disbursement, and a reasonable estimate of a
263 volume-based discount.
264 [
265 (i) an administrative fee[
266 (ii) any administrative fee excess.
267 (29) (a) "Reimbursement report" means a report on the adjustment in total
268 compensation for a claim.
269 (b) "Reimbursement report" does not include a report on adjustments made pursuant to
270 a pharmacy audit or reprocessing.
271 (30) "Retail pharmacy" means the same as that term is defined in Section 58-17b-102.
272 (31) "Sale" means a prescription drug or prescription device claim covered by a health
273 benefit plan.
274 (32) "Spread pricing" means the practice in which a pharmacy benefit manager charges
275 a health benefit plan a different amount for pharmacist services than the amount the pharmacy
276 benefit manager reimburses a pharmacy for the pharmacist's services.
277 [
278 U.S.C. Sec. 1395w-3a.
279 Section 4. Section 31A-46-301 is amended to read:
280 31A-46-301. Reporting requirements.
281 (1) Before April 1 of each year, a pharmacy benefit manager operating in the state shall
282 report to the department, for the previous calendar year:
283 (a) any insurer, pharmacy, or pharmacist in the state with which the pharmacy benefit
284 manager had a contract;
285 (b) the total value, in the aggregate, of [
286 administrative fee, and any administrative fee excess that [
287 contracting insurer; and
288 (c) if applicable, the percentage of aggregate rebates that the pharmacy benefit manager
289 retained under the pharmacy benefit manager's agreement to provide pharmacy benefits
290 management services to a contracting insurer.
291 (2) Records submitted to the commissioner under Subsections (1)(b) and (c) are a
292 protected record under Title 63G, Chapter 2, Government Records Access and Management
293 Act.
294 (3) (a) The department shall publish the information provided by a pharmacy benefit
295 manager under Subsection (1)(c) in the annual report described in Section 31A-2-201.2.
296 (b) The department may not publish information submitted under Subsection (1)(b) or
297 (c) in a manner that:
298 (i) makes a specific submission from a contracting insurer or pharmacy benefit
299 manager identifiable; or
300 (ii) is likely to disclose information that is a trade secret as defined in Section 13-24-2.
301 (c) At least 30 days before the day on which the department publishes the data, the
302 department shall provide a pharmacy benefit manager that submitted data under Subsection
303 (1)(b) or (c) with:
304 (i) a general description of the data that will be published by the department;
305 (ii) an opportunity to submit to the department, within a reasonable period of time and
306 in a manner established by the department by rule made in accordance with Title 63G, Chapter
307 3, Utah Administrative Rulemaking Act:
308 (A) any correction of errors, with supporting evidence and comments; and
309 (B) information that demonstrates that the publication of the data will violate
310 Subsection (3)(b), with supporting evidence and comments.
311 Section 5. Section 31A-46-304 is amended to read:
312 31A-46-304. Claims practices.
313 (1) A pharmacy benefit manager shall permit a pharmacy to collect the amount of a
314 customer's cost share from any source.
315 (2) A pharmacy benefit manager may not deny or reduce a reimbursement to a
316 pharmacy or a pharmacist after the adjudication of the claim, unless:
317 (a) the pharmacy or pharmacist submitted the original claim fraudulently;
318 (b) the original reimbursement was incorrect because:
319 (i) the pharmacy or pharmacist had already been paid for the pharmacy service; or
320 (ii) an unintentional error resulted in an incorrect reimbursement; or
321 (c) the pharmacy service was not rendered by the pharmacy or pharmacist.
322 (3) (a) A finding of overpayment or underpayment shall be based on the actual
323 overpayment or underpayment of a specific individual claim.
324 (b) Any amount to be charged back or recouped due to overpayment may not exceed
325 the amount the pharmacy was overpaid.
326 [
327 (a) any form of an investigation or audit of pharmacy records for fraud, waste, abuse,
328 or other intentional misrepresentation indicates that the pharmacy or pharmacist engaged in
329 criminal wrongdoing, fraud, or other intentional misrepresentation; or
330 (b) the reimbursement is reduced as the result of the reconciliation of a reimbursement
331 amount under a performance contract if:
332 (i) the performance contract lays out clear performance standards under which the
333 reimbursement for a specific drug may be increased or decreased; and
334 (ii) the agreement between the pharmacy benefit manager and the pharmacy or
335 pharmacist explicitly states, in a separate document that is signed by the pharmacy benefit
336 manager and the pharmacy or pharmacist, that the provisions of Subsection (2) do not apply.
337 Section 6. Section 31A-46-311 is enacted to read:
338 31A-46-311. Options for self-funded health benefit plans.
339 A pharmacy benefit manager shall offer to a self-funded health benefit plan, as an
340 option for the self-funded health benefit plan's design, pharmacy benefit management services
341 that:
342 (1) comply with the provisions of Subsections 31A-22-643(4) through (6), collectively
343 and individually; and
344 (2) do not include spread pricing.
345 Section 7. Section 58-17b-622 is amended to read:
346 58-17b-622. Pharmacy benefit management services -- Auditing of pharmacy
347 records -- Appeals.
348 (1) For purposes of this section:
349 (a) "Audit" means a review of the records of a pharmacy by or on behalf of an entity
350 that finances or reimburses the cost of health care services or pharmaceutical products.
351 (b) "Audit completion date" means:
352 (i) for an audit that does not require an on-site visit at the pharmacy, the date on which
353 the pharmacy, in response to the initial audit request, submits records or other documents to the
354 entity conducting the audit, as determined by:
355 (A) postmark or other evidence of the date of mailing; or
356 (B) the date of transmission if the records or other documents are transmitted
357 electronically; and
358 (ii) for an audit that requires an on-site visit at a pharmacy, the date on which the
359 auditing entity completes the on-site visit, including any follow-up visits or analysis which
360 shall be completed within 60 days after the day on which the on-site visit begins.
361 (c) "Entity" includes:
362 (i) a pharmacy benefits manager or coordinator;
363 (ii) a health benefit plan;
364 (iii) a third party administrator as defined in Section 31A-1-301;
365 (iv) a state agency; or
366 (v) a company, group, or agent that represents, or is engaged by, one of the entities
367 described in Subsections (1)(c)(i) through (iv).
368 (d) "Extrapolation" means a method of using a mathematical formula that uses the
369 audit results from a small sample of insurance claims and projects the results over a larger
370 group of insurance claims.
371 [
372 concealment in order to gain something of value.
373 [
374 (i) a health benefit plan as defined in Section 31A-1-301; or
375 (ii) a health, dental, medical, Medicare supplement, or conversion program offered
376 under Title 49, Chapter 20, Public Employees' Benefit and Insurance Program Act.
377 (2) (a) Except as provided in Subsection (2)(b), this section applies to:
378 (i) a contract for the audit of a pharmacy entered into, amended, or renewed on or after
379 July 1, 2012; and
380 (ii) an entity that conducts an audit of the pharmacy records of a pharmacy licensed
381 under this chapter.
382 (b) This section does not apply to an audit of pharmacy records:
383 (i) for a federally funded prescription drug program, including:
384 (A) the state Medicaid program;
385 (B) the Medicare Part D program;
386 (C) a Department of Defense prescription drug program; and
387 (D) a Veterans Affairs prescription drug program; or
388 (ii) when fraud or other intentional and willful misrepresentation is alleged and the
389 pharmacy audit entity has evidence that the pharmacy's actions reasonably indicate fraud or
390 intentional and willful misrepresentation.
391 (3) (a) An audit that involves clinical or professional judgment shall be conducted by
392 or in consultation with a pharmacist who is employed by or working with the auditing entity
393 and who is licensed in the state or another state.
394 (b) If an audit is conducted on site at a pharmacy, the entity conducting the audit:
395 (i) shall give the pharmacy 10 days advanced written notice of:
396 (A) the audit; and
397 (B) the range of prescription numbers or a date range included in the audit; and
398 (ii) may not audit a pharmacy during the first five business days of the month, unless
399 the pharmacy agrees to the timing of the audit.
400 (c) An entity may not audit claims:
401 (i) submitted more than 18 months prior to the audit, unless:
402 (A) required by federal law; or
403 (B) the originating prescription is dated in the preceding six months; or
404 (ii) that exceed 200 selected prescription claims annually.
405 (d) Subsection (3)(c)(ii) does not apply to any investigative audit that involves fraud,
406 waste, abuse, or willful misrepresentation.
407 (4) (a) An entity may not:
408 (i) include dispensing fees in the calculations of overpayments unless the prescription
409 is considered a misfill;
410 (ii) recoup funds for prescription clerical or recordkeeping errors, including
411 typographical errors, scrivener's errors, and computer errors on a required document or record
412 unless the audit entity is alleging fraud or other intentional or willful misrepresentation and the
413 audit entity has evidence that the pharmacy's actions reasonably indicate fraud or intentional
414 and willful misrepresentation;
415 (iii) recoup funds for refills dispensed in accordance with Section 58-17b-608.1, unless
416 the health benefit plan does not cover the prescription drug dispensed by the pharmacy;
417 (iv) collect any funds, charge-backs, or penalties until the audit and all appeals are
418 final, unless the audit entity is alleging fraud or other intentional or willful misrepresentation
419 and the audit entity has evidence that the pharmacy's actions reasonably indicate fraud or
420 intentional and willful misrepresentation; or
421 (v) recoup funds or collect any funds, charge-backs, or penalties from a pharmacy in
422 response to a request for audit unless the pharmacy confirms to the entity the date on which the
423 pharmacy received the request for audit.
424 (b) Auditors shall only have access to previous audit reports on a particular pharmacy
425 if the previous audit was conducted by the same entity except as required for compliance with
426 state or federal law.
427 (5) A pharmacy subject to an audit:
428 (a) may use one or more of the following to validate a claim for a prescription, refill, or
429 change in a prescription:
430 (i) electronic or physical copies of records of a health care facility, or a health care
431 provider with prescribing authority;
432 (ii) any prescription that complies with state law;
433 (iii) the pharmacy's own physical or electronic records; or
434 (iv) the physical or electronic records, or valid copies of the physical or electronic
435 records, of a practitioner or health care facility as defined in Section 26B-2-201; and
436 (b) may not be required to provide the following records to validate a claim for a
437 prescription, refill, or change in a prescription:
438 (i) if the prescription was handwritten, the physical handwritten version of the
439 prescription; or
440 (ii) a note from the practitioner regarding the patient or the prescription that is not
441 otherwise required for a prescription under state or federal law.
442 (6) (a) (i) An entity that audits a pharmacy shall establish:
443 (A) a maximum time for the pharmacy to submit records or other documents to the
444 entity following receipt of an audit request for records or documents; and
445 (B) a maximum time for the entity to provide the pharmacy with a preliminary audit
446 report following submission of records under Subsection (6)(a)(i)(A).
447 (ii) The time limits established under Subsections (6)(a)(i)(A) and (B):
448 (A) shall be identical; and
449 (B) may not be less than seven days or more than 60 days.
450 (iii) An entity that audits a pharmacy may not, after the audit completion date, request
451 additional records or other documents from the pharmacy to complete the preliminary audit
452 report described in Subsection (6)(b).
453 (b) An entity that audits a pharmacy shall provide the pharmacy with a preliminary
454 audit report[
455 (i) delivered to the pharmacy or its corporate office of record, within the time limit
456 established under Subsection (6)(a)(i)(B)[
457 (ii) that includes a notation for each suspected error.
458 (c) (i) Except as provided in Subsection (6)(c)(ii), a pharmacy has 30 days following
459 receipt of the preliminary audit report to respond to questions, provide additional
460 documentation, and comment on and clarify findings of the audit.
461 (ii) An entity may grant a reasonable extension under Subsection (6)(c)(i) upon request
462 by the pharmacy.
463 (iii) Receipt of the report under Subsection (6)(c)(i) shall be determined by:
464 (A) postmark or other evidence of the date of mailing; or
465 (B) the date of transmission if the report is transmitted electronically.
466 (iv) If a dispute exists between the records of the auditing entity and the pharmacy, the
467 records maintained by the pharmacy shall be presumed valid for the purpose of the audit.
468 (7) If an audit results in the dispute or denial of a claim, the entity conducting the audit
469 shall allow any of the following:
470 (a) the pharmacy to resubmit a claim using any commercially reasonable method,
471 including fax, mail, or electronic claims submission [
472
473 days from the day on which the audit report is received by the pharmacy; or
474 (b) the health benefit plan or other entity that finances or reimburses the cost of health
475 care services or pharmaceutical products to rerun the claim if the health benefit plan or other
476 entity chooses to rerun the claim at no cost to the pharmacy.
477 (8) (a) Within 60 days after the completion of the appeals process under Subsection
478 (9), a final audit report shall be delivered to the pharmacy or its corporate office of record.
479 (b) The final audit report shall include:
480 (i) a disclosure of any money recovered by the entity that conducted the audit[
481 (ii) legal or contractual information supporting any money recovered, recoupments, or
482 penalties included in the report.
483 (9) (a) An entity that audits a pharmacy shall establish a written appeals process for
484 appealing a preliminary audit report and a final audit report, and shall provide the pharmacy
485 with notice of the written appeals process.
486 (b) If the pharmacy benefit manager's contract or provider manual contains the
487 information required by this Subsection (9), the requirement for notice is met.
488 (10) An auditing entity conducting a pharmacy audit may not:
489 (a) use extrapolation when conducting an audit, including calculating recoupments or
490 penalties for audits, unless otherwise required by federal law or a self-funded health benefit
491 plan; or
492 (b) compensate an employee or contractor participating in the audit in a manner that is
493 based on the amount claimed or the actual amount recouped from the pharmacy being audited.
494 Section 8. Repealer.
495 This bill repeals:
496 Section 31A-46-101, Title.
497 Section 9. Intent language for the Public Employees' Benefit and Insurance
498 Program.
499 The Legislature intends that in order for the state employee health plan to comply with
500 Subsections 31A-22-643(4) through (6), the Public Employee's Benefit and Insurance Program
501 shall:
502 (1) implement a plan design that uses a combination of the methods described in
503 Subsections 31A-22-643(4)(a)(i) and (iv); and
504 (2) alter other aspects of plan design, employee premium share, or employer health
505 savings account contribution to ensure cost neutrality to the state.
506 Section 10. Effective date.
507 This bill takes effect on January 1, 2025.