Table of Contents TITLE 33. INSURANCE AND INSURANCE COMPANIES CHAPTER 22. DISABILITY INSURANCE Part 1. General Provisions

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33-22-101 — Exceptions to scope 33-22-102 — Third-party ownership 33-22-107 — Premium increase restrict... 33-22-109 — Riders 33-22-110 — Preexisting conditions 33-22-111 — Policies and certificates... 33-22-112 — Disability insurance cove... 33-22-113 — Disability insurance cove... 33-22-114 — Coverage required for ser... 33-22-115 — Provider agreement limite... 33-22-121 — Notice required for cance... 33-22-122 — Contents of notice – proo... 33-22-123 — Return of unearned premiu... 33-22-125 — Independent chiropractic... 33-22-129 — Coverage for outpatient s... 33-22-130 — Coverage for adopted chil... 33-22-131 — Coverage for treatment of... 33-22-132 — Coverage for mammography... 33-22-133 — Coverage for minimum hosp... 33-22-134 — Postmastectomy care 33-22-135 — Coverage for reconstructi... 33-22-136 — Insurance for spouse and... 33-22-137 — Cost-sharing requirements... 33-22-138 — Coverage for telemedicine... 33-22-139 — Coverage of therapies for... 33-22-140 — Definitions 33-22-141 — Crediting previous covera... 33-22-142 — Certification of creditab... 33-22-143 — Rules 33-22-150 — Reciprocal limitations on... 33-22-151 — Offset agreement 33-22-152 — Continuation of dependent... 33-22-153 — Coverage of routine patie... 33-22-156 — Health insurance rates –... 33-22-157 — Standards for review – no... 33-22-158 — Trade secret disclosure e... 33-22-159 — Rulemaking 33-22-170 — Definitions 33-22-171 — Maximum allowable cost li... 33-22-172 — Maximum allowable cost li... 33-22-173 — Maximum allowable cost –...

Mont. Code Ann. § 33-22-173

(2015)

Maximum allowable cost – appeals process

(1) In contracting with a pharmacy, a plan sponsor or pharmacy benefit manager shall:

(a) provide a procedure by which a pharmacy may appeal the price of a drug or drugs on the maximum allowable cost list;

(b) provide a telephone number at which a network pharmacy may contact the pharmacy benefit manager to discuss the status of the pharmacy's appeal; and

(2) If the final determination is a denial of the pharmacy's appeal, the pharmacy benefit manager shall state the reason for the denial and provide the national drug code of an equivalent drug that is available for purchase by pharmacies in this state from national or regional wholesalers at a price that is equal to or less than the maximum allowable cost for that drug.

(3) If a pharmacy's appeal is determined to be valid by the pharmacy benefit manager, the pharmacy benefit manager shall:

(a) make an adjustment in the drug price effective on the date the appeal is resolved;

(b) make the adjustment applicable to all similarly situated network pharmacy providers as determined by the plan sponsor or the pharmacy benefit manager, as appropriate; and

(c) permit the appealing pharmacy to reverse and rebill the claim in question, using the dates of the original claim or claims.

(4) A pharmacy benefit manager shall make price adjustments to all similarly situated pharmacies within 3 days.

(5) A pharmacy shall file its appeal within 10 calendar days of its submission of the initial claim for reimbursement.

Comparison view: showing changes between 2015 and the current version (2025). Green underlined text was added. Red strikethrough text was removed.

(1) In contracting with a ~~pharmacy,~~ a pharmacy plan or a sponsor pharmacy services administrative organization, a plan sponsor or pharmacy benefit manager shall:

(a) provide a procedure by which a pharmacy may or appeal a pharmacy services administrative organization may appeal the price of a drug or drugs on the maximum allowable cost list;

(b) provide a telephone number at which a network pharmacy may contact the pharmacy benefit manager to discuss the status of the pharmacy's appeal; and

(2) If the final determination is a denial of the pharmacy's or appeal, the the pharmacy services administrative organization's appeal, pharmacy the pharmacy benefit manager shall state the reason for the denial and provide the national drug code of an equivalent drug that is available for purchase by pharmacies in this state from national or regional wholesalers at a price that is equal to or less than the maximum allowable cost for that drug.

(3) If a pharmacy's or a appeal pharmacy services administrative organization's appeal is determined to be valid by the pharmacy benefit manager, the pharmacy benefit manager shall:

(a) make an adjustment in the drug price effective on the date the appeal is resolved;

(b) make the adjustment applicable to all similarly situated network pharmacy providers as determined by the plan sponsor or the pharmacy benefit manager, as appropriate; and

(c) permit the appealing pharmacy to reverse and rebill the claim in question, using the dates of the original claim or claims.

(4) A pharmacy benefit manager shall make price adjustments to all similarly situated pharmacies within 3 days.

(5) A pharmacy or a pharmacy services administrative organization shall file its appeal within 10 calendar days from of the ~~its submission~~ time of denial by the ~~initial claim for reimbursement.~~ pharmacy benefit manager.

Maximum allowable cost – appeals process

Official Annotations archive.org, 2015 edition

History:

EnactedEn. SectionSec. 4, ChapterCh. 431, Laws ofL. 2015 (SB 211 - Buttrey, Edward (R) SD 11)

Source text on leg.mt.gov