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S.F. No. 973 establishes procedures that must be followed during pharmacy audits. The bill also establishes procedures for modifying contracts between pharmacy benefit managers (PBMs) and pharmacies.
Section 1 (151.60) states that the pharmacy audit integrity program is established to provide standards for an audit of pharmacy records.
Section 2 (151.60) defines the following terms: “audit contractor,” “entity,” “insurance company,” “managed care company,” “pharmacy benefits manager or PBM,” “state agency health program,” and “third-party payor.”
Section 3 (151.62) permits a PBM to alter or amend a current contract with a pharmacy, but states that the changes are not effective without the written consent of the pharmacy. The pharmacy must receive a copy of the proposed changes or renewal and a disclosure of all material changes from the previous contract. Any amendment or change to the terms of an existing contract must be disclosed to the pharmacy at least 120 days prior to the effective date of the proposed change. In order to alter or amend a contract or impose any additional contractual obligations on a pharmacy, a PBM must comply with this section.
Section 4 (151.63) specifies procedures that must be followed by any entity conducting a pharmacy audit.
Section 5 (151.64) requires a preliminary audit report to be delivered to a pharmacy within 30 days after conclusion of the audit. Permits a pharmacy 30 days following receipt of the audit to provide documentation to address any discrepancies. Requires a final audit report to be delivered to the pharmacy within 90 days after receipt of the preliminary audit report or final appeal, whichever is later. Prohibits any chargebacks, recoupment, or other penalties from being assessed until the appeals process has been exhausted and a final report is issued. Requires an entity that owes pharmacy money as a result of an underpayment of a claim to remit payment within 30 days after the appeals process has been exhausted and the final report issued. Prohibits the sharing of audit information unless superseded by state or federal law. States that an auditor shall only have access to previous audit reports on a particular pharmacy conducted by the same auditing entity.
Section 6 (151.65) requires an auditing entity to provide a copy of the final report to the plan sponsor whose claims were included in the audit. Requires money to be returned to the plan sponsor and the co-payment returned directly to the patient.
Section 7 (151.66) states that Minnesota Statutes, sections 151.60 to 151.66, do not apply to any investigative audit that involves fraud, willful misrepresentation, or abuse. Lists specific circumstances under which those sections do not apply. Requires all cases of suspected fraud or violations of law to be reported by the auditor to the Board of Pharmacy.
Section 8 establishes an effective date.
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