Pharmacy Appeals Multi-source Generic Drug Reimbursement Appeal Process FAQs In 2018, HB 240 was enacted. This legislation requires Pharmacy Benefits Managers (PBMs) to register with the director of insurance as a third party administrator. It sets procedures PBMs must follow when conducting pharmacy audits, establishes procedures related to drug pricing, and allows a pharmacy to request a hearing if the appeal process results in an adverse decision from a PBM. Please note, the Division of Insurance may grant an appeal request only if the contested reimbursement amount pertains to a prescription filled for a customer covered by a fully insured, non-ERISA plan. Who can request a hearing with the director of the Division of Insurance? Alaska Statute (AS) 21.27.950(e) states that a network pharmacy may request a hearing under AS 21.06.170 - 21.06.240 for an adverse decision from a pharmacy benefits manager within 30 calendar days after receiving the decision. The parties may present all relevant information to the director for the director's review. What can I expect if I submit a request for a hearing? The Division will review the hearing request along with all submitted documentation to determine whether or not the adverse decision received at the conclusion of the PBM internal appeal process is consistent with Alaska State law. If it is determined that the Division has jurisdiction over the plan associated with the disputed reimbursement the hearing request will be referred to the Alaska Office of Administrative Hearings (OAH). The OAH may then conduct a hearing in order to come to a proposed resolution. Following the OAH hearing and the Division’s investigation, the director will provide a decision that may grant the network pharmacy's appeal and direct the PBM to make an adjustment to the disputed claim; or deny the network pharmacy's appeal; or direct other actions considered fair and equitable. What should I submit in order to request a hearing? In order to request a hearing with the director of insurance, a network pharmacy should complete and submit a Multi-Source Generic Drug Appeal Hearing Request Form along with a copy of the final decision reached following the conclusion of the PBM internal appeal process. Please do not include any personally identifiable information (PII) or details that might violate the Health Insurance Portability and Accountability Act of 1996 (HIPAA). How can I request a hearing? If you would like to request a hearing, please fill out the hearing request form and send it to firstname.lastname@example.org. If you have questions, please contact the Division of Insurance at email@example.com or 907-465-2515.