Tenn. Comp. R. & Regs. 0780-01-95-.09 - AUDITS BY PHARMACY BENEFITS MANAGERS

(1) A PBM's recoupment of funds from a pharmacy after an audit pursuant to T.C.A. § 56-7-3103 may not reduce the pharmacy's compensation for the prescription drug or device at issue to an amount that is less than the pharmacy's actual cost for the prescription drug or device as of the date the audit is commenced unless specifically allowed in law.

(2) When a PBM's audit of a pharmacy pursuant to T.C.A. § 56-7-3103 results in a recoupment, in addition to any other requirement imposed in law or rule, a PBM shall include in the documentation of the audit information that demonstrates how the recoupment did not result in the pharmacy receiving less than its actual cost for each affected prescription drug or device at issue, including but not limited to:

(a) The rationale that led the PBM to decide the pharmacy was overpaid for each claim that is subject to recoupment, along with supporting documentation; and

(b) An itemized breakdown for each claim that is subject to recoupment showing, at least, a comparison of what the pharmacy actually received and what the pharmacy should have received.

(3) A PBM shall retain all records related to an audit of a pharmacy pursuant to T.C.A. § 56-7-3103 for the greater of five years or until the PBM is audited by the Department. A PBM shall provide the Department access to all records upon request and comply with requests for information regardless of whether the request is part of a departmental audit.

(4) This rule does not limit or prohibit a PBM's ability to audit a pharmacy or recoup funds as allowed by T.C.A. § 56-7-3103.

Notes

Tenn. Comp. R. & Regs. 0780-01-95-.09

Emergency rules filed December 29, 2022; effective through June 27, 2023. New rules filed March 29, 2023; effective 6/27/2023.

Authority: T.C.A. §§ 56-7-3101 and 56-7-3206.