OklahomaSB 993Oklahoma 2026 Regular SessionSenateWALLET

Pharmacy benefit managers; establishing requirements and limits for certain audit reports and findings. Emergency.

Sponsored By: Todd Gollihare (Republican)

Became Law

Senate Committee

Personalized for You

How does this bill affect your finances?

Personalize government policy and PRIA will tell you what this bill means for your household, plus every other piece of legislation we track. PRIA reads each provision against your financial profile to show you exactly what matters to your wallet.

Free to download

Bill Overview

Analyzed Economic Effects

12 provisions identified: 8 benefits, 1 costs, 3 mixed.

Patients protected from extra appeal charges

When a pharmacy wins a below-cost payment appeal, the pharmacy benefit manager cannot require extra collections from patients or plan sponsors. The manager that handled the claim is responsible for the added payment. When an audit recovers money originally paid by a patient, that money must be refunded to the patient first.

Pharmacies face fewer network licensing barriers

Pharmacy benefit managers cannot require extra accreditation or licensing as a condition of joining their networks. This protects providers and entities licensed or regulated by the Oklahoma State Board of Pharmacy. Managers cannot demand credentials beyond those required by that board or a federal government entity.

Pharmacies get audit caps and notice

Under ordinary audit rules, pharmacy benefit managers and their agents may audit no more than 50 claims per pharmacy each calendar year. Related document requests by third parties for managers or insurers count toward that cap. Certified notices must list prescription numbers, fill dates, drug names, and National Drug Codes at least 14 calendar days before an audit. Wholesale purchase audits require 30 calendar days' notice. Pharmacies must be allowed to reschedule within seven calendar days. Audits generally cover only one year of claims unless law requires longer, and need written consent during a month's first seven days. Auditors must use equal standards for similar pharmacies and minimize disruption to patient care. They cannot estimate repayments or penalties from samples, including unlisted refills, or assess financial penalties without a valid repayment claim. Wholesale reviews are limited to inventory checks tied to paid claims and cannot require full dispensing reports. Audits started because of suspected fraud, willful misrepresentation, or abuse are exempt from specified notice and audit-limit rules.

Pharmacies get clearer drug payment rules

Pharmacy benefit managers must disclose maximum allowable cost pricing sources in contracts, update prices every seven calendar days, and provide each provider's applicable list. Listed drugs must have an A or B rating in the FDA Orange Book, be generally available from national or regional wholesalers in Oklahoma, and not be obsolete. At least two equivalent, multiple-source drugs must also be generally available to dispensing retail pharmacies from those wholesalers. Dispensing fees must stay outside maximum allowable cost reimbursement calculations. For drugs in the FDA Drug Shortages Database, managers must pay at least the wholesale acquisition cost for the specific National Drug Code dispensed.

Pharmacies get disaster pauses and extensions

In affected counties, declared disasters pause a pharmacy benefit manager's ability to start, continue, or finish contractual pharmacy audits. The pause lasts through the disaster and 30 calendar days after it ends. It excludes documented suspected-fraud audits and audits required by state or federal law for reasons unrelated to the contract. An audit can continue or finish with both parties' signed written agreement or Attorney General approval. Below-cost appeal filing periods also pause during the declaration and for 30 calendar days afterward, then resume. This covers disaster-affected claims when the provider, representative, or pharmacy service organization is in a county included in the disaster area. Managers cannot reject qualifying appeals as late when filed during the pause.

Pharmacies get faster payment appeals

Pharmacies and their representatives have 14 calendar days after the final adjusted payment date to appeal reimbursement. Pharmacy benefit managers must respond within 10 calendar days and accept and answer electronic batch appeals without individual uploads or downloads. Appeals cover all drugs, medical products, and devices under any payment method, not just maximum allowable cost pricing. When an appeal shows a price update is needed, managers must apply it retroactively to all contracted providers and allow reversal and rebilling. Managers must provide a dedicated phone number, email address, and names of staff authorized to decide pricing and appeals.

Pharmacies get proof for appeal denials

A manager denying a below-cost appeal must explain why and name a specific national or regional wholesaler in Oklahoma. It must identify the drug's National Drug Code and document that the wholesaler has it in stock below the reimbursement price. If that code is unavailable below the pharmacy's acquisition cost from its main prescription-drug wholesaler, the manager must immediately adjust payment. The manager must allow reversal and rebilling and apply the adjustment retroactively to all contracted providers. An appeal increase that still leaves payment below the pharmacy's acquisition cost counts as a denial and requires the same proof.

Pharmacies get time to dispute findings

Ordinary audits require preliminary findings within 45 calendar days after the audit and signed final findings within 10 calendar days after documentation arrives. Suspected-fraud audits require preliminary findings within 90 calendar days after pharmacy notification and signed final findings within 30 calendar days after documentation arrives. In both cases, pharmacies get at least 90 calendar days to provide documents and may request up to 45 more. Pharmacies have 30 calendar days after the final report to electronically reverse and resubmit claims instead of immediate repayment. Disputed money cannot be collected until final disposition and appeals are exhausted, and no interest accrues during audits or appeals. Reports must include required claim and document-receipt details. Plan sponsors receive final results within 30 calendar days after final disposition and requested final reports within 30 calendar days. Auditors must accept relevant computerized medical records and redacted supplier invoices or legally authorized supplier documents. Clerical errors are not fraud and may be corrected through amended claims; requested supporting documents must be provided within five calendar days. Auditors must pay $0.25 per page for requested paper records, and their charges must follow contract terms allowed by the act. Charges based on a share of recovered money are barred unless expressly allowed by a contract consistent with the act.

Pharmacy benefit managers face stronger enforcement

The Attorney General, authorized staff, and examiners can access pharmacy benefit manager records related to any audit, not just suspected-fraud audits. The Attorney General and Insurance Department can subpoena records and copy materials for investigations. The Attorney General can impose fines of $100 to $10,000 per violation and seek license censure, suspension, or revocation. Each day a manager fails to comply with an investigation or inquiry may count as another violation. License action requires notice and a chance for a hearing; the Commissioner must enforce Attorney General instructions within 30 calendar days. The Insurance Department may deny, suspend, revoke, or decline to renew licenses for noncompliance, deceptive conduct, or unpaid fees. The Attorney General can void noncompliant audits and require recovered money to be returned within 14 calendar days.

Pharmacies can decline below-cost patient services

An Oklahoma pharmacy or pharmacist can decline clinical or dispensing services when payment is below the pharmacy's cost of providing them. This applies to services for a patient or pharmacy benefit manager. Pharmacies are not required to refuse service, but patients can lose access when a pharmacy uses this option.

Fraud audits get exceptions and oversight

Audits started because of suspected fraud, willful misrepresentation, or abuse bypass specified ordinary notice, audit-limit, and reporting rules. Concerns that arise later do not create this exception. At the audit, the auditor must give the pharmacy a clear written statement of facts supporting reasonable suspicion. A copy must reach the pharmacy's contracting agent by certified mail within five business days after pharmacy notification. The auditor must notify the Attorney General at least two calendar days before starting the audit. Preliminary reports go to the Attorney General within five business days after delivery to the pharmacy and contracting agent. Final reports go within 10 calendar days after the final appeal period closes. Auditors may request extensions of up to 90 calendar days for preliminary reports and 10 calendar days for final reports. Reports must include required plan sponsor, repayment, payment, and contact details. When fraud or willful misrepresentation is referred to a district attorney, the Attorney General must receive the recipient's identity and referral date.

Pharmacy benefit managers need state licenses

Pharmacy benefit managers and entities acting as managers for covered entities must obtain an Oklahoma Insurance Department license before providing services. Applications require a fee, a contact for legal notices, and proof of a surety bond. The definition also covers people and entities acting for a pharmacy benefit manager. Employers generally are not managers of their own self-funded health plans. To the extent allowed by law, an employer counts as one when it directly negotiates with drugmakers, processes member claims, or manages its retail pharmacy network without a third party and unrelated to its own pharmacy.

Sponsors & Cosponsors

Sponsor

Todd Gollihare
Republican • Senate

Cosponsors

Darcy Jech
Republican • Senate
Stinson
Affiliation unavailable

Roll Call Votes

All Roll Calls

Yes: 203 • No: 0

Senate vote • 5/14/2025

FOURTH READING

Yes: 40 • No: 0

House vote • 5/7/2025

THIRD READING

Yes: 89 • No: 0

House vote • 4/14/2025

DO PASS

Yes: 13 • No: 0

House vote • 4/9/2025

DO PASS

Yes: 6 • No: 0

Senate vote • 3/25/2025