Pharmacy Benefit Managers and Payment of Pharmacy Claims

Wyo. Stat. Ann. tit. 26, ch. 52

in effect

Wyo. Stat. Ann. § 26-52-101 Licensure of pharmacy benefit managers.

No person shall act or hold himself out as a pharmacy benefit manager in this state unless he obtains a license from the department. The department shall through rules establish license requirements and procedures for the licensing of pharmacy benefit managers consistent with this article. The requirements shall only provide for the adequate identification of licensees and the payment of the required licensing fee.

Wyo. Stat. Ann. § 26-52-102 Definitions.

(a) As used in this article: (i) "Claim" means a request from a pharmacy or pharmacist to be reimbursed for the cost of filling or refilling a prescription for a drug or for providing a medical supply or device; (ii) "Insurer" means the entity defined in W.S. 26-1-102(a)(xvi) and who provides health insurance coverage in this state; (iii) "List" means the list of drugs for which a pharmacy benefit manager has established a maximum allowable cost; (iv) "Maximum allowable cost" means the maximum amount that a pharmacy benefit manager will reimburse a pharmacist or pharmacy for the cost of a generic drug; (v) "Network providers" means those pharmacies that provide covered health care services or supplies to an insured or a member pursuant to a contract with a network plan to act as a participating provider; (vi) "Pharmacy" means an entity through which pharmacists or other persons practice pharmacy as specified in W.S. 33-24-124; (vii) "Pharmacy benefit manager" means an entity that contracts with a pharmacy or the pharmacy's designee who holds a contract with the pharmacy benefit manager on behalf of an insurer or third party administrator to administer or manage prescription drug benefits; (ix) "Pharmacy services" means any product, good or service, or any combination of products, goods or services, provided as part of the practice of pharmacy; (x) "Pharmacy services administrative organization" means an organization that evaluates and executes pharmacy benefit manager contracts on behalf of pharmacies and provides administrative, clerical, audit and data analytics support services.

Wyo. Stat. Ann. § 26-52-103 Pharmacy benefit manager audits.

(a) Any pharmacy benefit manager or person acting on behalf of a pharmacy benefit manager who conducts an audit of a pharmacy shall follow the following procedures: (i) Provide written notice to the pharmacy not less than ten (10) business days before conducting any on-site, initial audit; (ii) Conduct any audit requiring clinical or professional judgment through or in consultation with a licensed pharmacist; (iii) Limit the period covered by the audit to not more than two (2) years from the date that an audited claim was adjudicated; (iv) Allow verifiable statements or records, including medication administration records of a nursing home, assisted living facility, hospital, physician or other authorized practitioner, to validate the pharmacy record; (v) Allow legal prescriptions, including medication administration records, faxes, electronic prescriptions or documented telephone calls from the prescriber or the prescriber's agent, to validate claims in connection with prescriptions, refills or changes in prescriptions; (vi) Apply the same standards and parameters to each audited pharmacy as are applied to other similarly situated pharmacies in a pharmacy network contract in this state; (vii) Not conduct any audit provided for in this section during the first seven (7) calendar days of any month without the consent of the audited pharmacy; and (viii) Establish a written appeals process and provide a copy to every audited pharmacy. (b) A pharmacy benefit manager or person acting on behalf of a pharmacy benefit manager who conducts an audit of a pharmacy also shall comply with the following requirements: (i) Any finding of overpayment or underpayment shall be based 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; (ii) Any finding of an overpayment shall not include the dispensing fee amount unless: (A) A prescription was not received by the patient or the patient's designee; (B) The prescriber denied authorization; (C) The prescription dispensed was a medication error by the pharmacy; or (D) The identified overpayment is based solely on an extra dispensing fee. (iii) No audit shall use extrapolation in calculating the recoupments or penalties for audits, unless required by state or federal contracts; (iv) No payment for the performance of an audit shall be based on a percentage of the amount recovered; (v) Interest shall not accrue during the audit period; (vi) No audit shall consider any clerical or recordkeeping error, such as a typographical error, scrivener's error or computer error regarding a required document or record, as fraud. These errors may be subject to recoupment. No recovery shall be assessed for errors causing no financial harm to the patient or plan. Errors that are the result of a pharmacy failing to comply with a formal corrective action plan may be subject to recovery. Any recoupment shall be based on the actual overpayment of a claim; (vii) A preliminary audit report shall be delivered to the audited pharmacy within one hundred twenty (120) days after the conclusion of the audit; (viii) A pharmacy shall be allowed at least thirty (30) days following receipt of the preliminary audit report to provide documentation addressing any audit finding, and a reasonable extension of time shall be granted upon request; (ix) A final audit report shall be delivered to the pharmacy not more than one hundred twenty (120) days after the preliminary audit report is received by the pharmacy or submission of final internal appeal, whichever is later; (x) Recoupment of any disputed funds or repayment of funds to the pharmacy benefit manager or insurer by the pharmacy, if permitted pursuant to contracts, shall occur, to the extent demonstrated or documented in the pharmacy audit findings, after final internal disposition of the audit including the appeals process. If the identified discrepancy for an individual audit exceeds fifteen thousand dollars ($15,000.00), any future payments to the pharmacy may be withheld pending finalization of the audit; (xi) No chargebacks, recoupment or other penalties may be assessed until the appeal process has been exhausted and the final report issued. (c) Subsections (a) and (b) of this section shall not apply to: (i) Audits in which suspected fraudulent activity or other intentional or willful misrepresentation is evidenced by a physical review, review of claims data, statements or other investigative methods; or (ii) Audits of claims paid for by federally funded programs. (d) This section shall apply to a contracted pharmacy, or the pharmacy's designee who holds a contract with a pharmacy benefit manager, entered into, renewed or extended on or after July 1, 2016, and to all audits of pharmacies on and after July 1, 2017.

Wyo. Stat. Ann. § 26-52-104 Maximum allowable cost; offering information and alternatives.

(a) To place a drug on a maximum allowable cost list, a pharmacy benefit manager shall ensure that the drug is: (i) If the drug is a generically equivalent drug, rated "A" or "B" in the most recent version of the United States Food and Drug Administration's Approved Drug Products with Therapeutic Equivalence Evaluations (Orange Book), or rated "NR" or "NA," or has a similar rating, by a nationally recognized reference; (ii) Generally available for purchase by retail pharmacies in the state from national or regional wholesalers; (iii) Not obsolete or temporarily unavailable. (b) In formulating the maximum allowable cost price for a drug, an insurer or pharmacy benefit manager shall consider only the price of that drug and any drug listed as therapeutically equivalent to that drug in the most recent version of the United States Food and Drug Administration's Approved Drug Products with Therapeutic Equivalence Evaluations (Orange Book). (c) Notwithstanding subsection (b) of this section, if a therapeutically equivalent generic drug is unavailable or has limited market presence, an insurer or pharmacy benefit manager may place on a maximum allowable cost list a drug that has: (i) A "B" rating in the most recent version of the United States Food and Drug Administration's Approved Drug Products with Therapeutic Equivalence Evaluations (Orange Book); or (ii) An "NR" or "NA" rating, or a similar rating, by a nationally recognized reference. (d) A pharmacy benefit manager shall: (i) Make available to each network provider at the beginning of the term of the network provider's contract, and upon renewal of the contract, the sources utilized to determine the maximum allowable cost pricing; (ii) Provide a telephone number, email address and website at which a network pharmacy or the pharmacy's designee who holds a contract with the pharmacy benefit manager may contact an employee of a pharmacy benefit manager to discuss the pharmacy's appeal; (iii) Provide a process for network providers to readily access the maximum allowable cost applicable to that provider; (iv) Review and update applicable maximum allowable cost price information at least once every seven (7) business days to reflect any modification of maximum allowable cost pricing; and (v) Ensure that dispensing fees are not included in the calculation of maximum allowable cost. (e) A pharmacy benefit manager shall establish a process by which a contracted pharmacy, or the pharmacy's designee who holds a contract with the pharmacy benefit manager, can appeal the provider's reimbursement for a drug subject to maximum allowable cost pricing. A contracted pharmacy, or the pharmacy's designee who holds a contract with the pharmacy benefit manager, shall have up to ten (10) business days after dispensing a drug subject to a maximum allowable cost in which to appeal the amount of the maximum allowable cost. A pharmacy benefit manager shall respond to the appeal within ten (10) business days after the contracted pharmacy or the pharmacy's designee who holds a contract with the pharmacy benefit manager makes the appeal. (f) If a maximum allowable cost appeal is denied, the pharmacy benefit manager shall provide to the appealing pharmacy, or the pharmacy's designee who holds a contract with the pharmacy benefit manager, the reason for the denial and the national drug code number for the drug that is available for purchase by similarly situated pharmacies in the state and the names of national or regional wholesalers that have the product available for purchase at a price that is at or below the maximum allowable cost. (g) If an appeal is upheld, the pharmacy benefit manager shall make an adjustment to the applicable maximum allowable cost no later than one (1) day after the date of the determination and make the adjustment applicable to all similarly situated network pharmacy providers, as determined by the insurer or pharmacy benefit manager. The pharmacy benefit manager shall allow the appealing pharmacy to reverse and rebill the claim which was the subject of the appeal. (h) This section shall apply to a contracted pharmacy, or the pharmacy's designee who holds a contract with a pharmacy benefit manager, entered into, renewed or extended on or after July 1, 2016, and to contracts on and after July 1, 2017. (j) A pharmacy benefit manager may not, by contract or otherwise, prohibit or penalize a pharmacy or pharmacist for: (i) Disclosing information to a covered individual regarding any cost differential that the covered individual must pay for a particular prescription under the individual's prescription drug benefit or outside of the individual's prescription drug benefit; (ii) Offering to a covered individual a more affordable alternative if one is available. (k) A pharmacy benefit manager shall not prevent a network pharmacy or the pharmacy's designee who holds a contract with the pharmacy benefit manager from filing appeals in an electronic batch format. The pharmacy benefit manager shall respond in an electronic format to valid reimbursement appeals filed in an electronic batch format. A batch appeal shall not be considered a valid appeal unless all required information for each claim in the batch is submitted electronically with the correct, contractually required information and in the required format. An appeal shall not be considered valid for purposes of the ten (10) day response timeframe until all information is received. (m) A pharmacy or pharmacist may decline to provide pharmacy services to a patient or pharmacy benefit manager if the pharmacy or pharmacist is to be paid less than the pharmacy acquisition cost for the pharmacy providing pharmacy services.

Wyo. Stat. Ann. § 26-52-105 Transparency; prohibitions.

(a) A pharmacy benefit manager or an agent of a pharmacy benefit manager shall not: (i) Cause or knowingly permit the use of an advertisement, promotion, solicitation, representation, proposal or offer that is untrue, deceptive or misleading; (ii) Charge a pharmacist or pharmacy provider a fee for any of the following: (A) The submission of a claim; (B) Enrollment or participation in a retail pharmacy network; (C) The development or management of claims processing services or claims payment services related to participation in a retail pharmacy network; (D) An application to apply for network access with the pharmacy benefit manager; (E) Credentialing or re-credentialing. (iii) Retroactively deny or reduce reimbursement for a covered pharmacy service or claim after adjudication of the claim, unless: (A) The original claim was fraudulent; or (B) The denial or reduction is necessary to correct errors found in an audit, provided that the audit was conducted in compliance with W.S. 26-52-103. (vii) Prohibit a pharmacy, pharmacy services administrative organization, contracting agent or agent of a pharmacy from sharing, upon request, copies of pharmacy benefit manager contracts with the department of insurance; (viii) Prohibit, restrict or limit disclosure of information to the insurance commissioner, law enforcement or other state or federal government officials who are investigating or examining a complaint or conducting a review of the pharmacy benefit manager's compliance with the requirements of this chapter. (c) Insurers, pharmacies and pharmacy benefit managers shall adhere to all state laws and rules when mailing or shipping prescription drugs into the state.

Wyo. Stat. Ann. § 26-52-106 Alternate reimbursement methodologies.

All contracts between a pharmacy benefits manager and a pharmacy services administrative organization, or its contracted pharmacies, and all contracts directly between a pharmacy benefits manager and a pharmacy shall include a process to investigate and resolve disputes.

Wyo. Stat. Ann. § 26-52-107 Certain claims excluded.

W.S. 26-52-104 through 26-52-106 shall apply to all health benefit plan issuers and pharmacy benefit managers except those claims associated with the Wyoming Medicaid fee-for-service program, the Wyoming workers compensation division or those claims otherwise prohibited by federal law.

Wyo. Stat. Ann. § 26-52-201 Scope and applicability of chapter.

The following provisions apply to situations where there is a contract between an insurer or the insurer's intermediary and a pharmacy regarding the payment of insurance claims for pharmacy services pursuant to W.S. 26-52-102(a)(ix) submitted to an insurer or the insurer's intermediary.

Wyo. Stat. Ann. § 26-52-202 Definitions.

(a) As used in this chapter: (i) "Applicable number of calendar days" means: (A) For claims submitted electronically, twenty-one (21) days; (B) For claims submitted in a manner other than electronically, thirty (30) days. (ii) "Clean claim" means a claim that has no defect, including any lack of required substantiating documentation or particular circumstance requiring special treatment that prevents timely payment from being made on the claim under this chapter; (iii) "Insurer" means as defined by W.S. 26-1-102(a)(xvi).

Wyo. Stat. Ann. § 26-52-203 Payment of claims to pharmacy providers.

(a) A contract between an insurer or the insurer's intermediary and a pharmacy for prescription drug coverage offered by the insurer or the insurer's intermediary shall require the insurer or the insurer's intermediary to make payment to the pharmacy for all clean claims submitted by a pharmacy within the applicable number of calendar days after the date that the clean claim is received. For purposes of this section, a claim is considered to have been received: (i) For claims submitted electronically, on the date that the claim is submitted; or (ii) For claims submitted in any manner other than electronically, on the fifth day after the postmark date of the claim or the date specified on the time stamp of the transmission of the claim. (b) For purposes of this section, a contract between an insurer or the insurer's intermediary and a pharmacy regarding prescription drug coverage offered by an insurer or the insurer's intermediary shall include any contract regarding prescription drug coverage offered by the insurer or the insurer's intermediary under which a pharmacy is legally obligated, either directly or through an intermediary such as a pharmacy benefit manager. (c) If the insurer or the insurer's intermediary does not make payment within the applicable number of calendar days after a clean claim is received, or resubmitted under subsections (e) and (f) of this section, the insurer or the insurer's intermediary shall pay interest to the pharmacy at the rate of eighteen percent (18%) per annum, billed weekly. (d) A claim shall be considered a clean claim if the insurer or the insurer's intermediary does not provide notice to the pharmacy of any deficiency in the claim within ten (10) days after an electronically submitted claim is received or within fifteen (15) days after a claim that is submitted in any other manner is received. (e) If an insurer or the insurer's intermediary determines that a claim submitted is not a clean claim, the insurer or the insurer's intermediary shall notify the pharmacy of the determination within ten (10) days of receiving an electronically submitted claim or within fifteen (15) days of receiving a claim that is submitted in any other manner. The notice shall specify all defects in the claim and list all information or documents necessary for the proper processing and payment of the claim. (f) A claim resubmitted to an insurer or the insurer's intermediary with additional information pursuant to subsection (e) of this section shall be considered to be a clean claim if the insurer or the insurer's intermediary fails to provide notice to the pharmacy of any defect in the claim within ten (10) days of the date that additional information is received if the claim is resubmitted electronically or within fifteen (15) days of the date that additional information is received if the claim is resubmitted in any other manner. A resubmitted claim that is considered to be a clean claim under this subsection shall be paid within the applicable number of calendar days after the date that the resubmitted claim is received and, if payment is not timely made, interest shall accrue as provided by subsection (c) of this section. (g) Payment of a clean claim under this section shall be considered to have been made on the date that the payment is transferred to the pharmacy provider account, or to the central pay account of the pharmacy services administrative organization that is directly contracted by the pharmacy, with respect to claims paid electronically and on the date that the payment is submitted to the postal service or common carrier for delivery with respect to claims paid in any other manner. (h) No insurer shall directly or indirectly charge a pharmacy or hold the pharmacy responsible for fees associated with claims payment.

Source: WY Statutes (Official Site)URL: https://wyoleg.gov/statutes/compress/title26.pdfFetched: 10/4/2026