Appeals [For application of this section, see 80 Del. Laws, c. 245, § 2; 83 Del. Laws, c. 256, § 15; 85 Del. Laws, c. 481, § 7].
Del. Code tit. 18, § 3324A
in effect(a) (1) a. A pharmacy benefits manager must establish a process by which a contracted pharmacy can appeal the amount of the provider’s reimbursement for a drug that was reimbursed by the pharmacy benefits manager.
b. A contracted pharmacy’s representative may take actions and receive notices under this section on behalf of the contracted pharmacy.
(2) A contracted pharmacy has 40 calendar days after the applicable fill date to appeal a reimbursement if the reimbursement for the drug is less than any of the following:
a. The net amount that the network provider paid to the supplier of the drug.
b. The reimbursement amount required under § 3372A(7) of this title.
(3) A pharmacy benefits manager must respond with notice that the appeal has been denied or granted within 10 calendar days of the contracted pharmacy making the claim for which an appeal has been submitted.
(b) At the beginning of the term of a network provider’s contract, and upon renewal, a pharmacy benefits manager must provide to network providers a telephone number and e-mail address at which a network provider can contact the pharmacy benefits manager to process an appeal under this section.
(c) (1) If an appeal is denied, the pharmacy benefits manager must provide a detailed reason for the denial. If the appeal is related to a maximum allowable cost reimbursement, the pharmacy benefits manager must also provide the name and national drug code number of the national or regional wholesalers operating in this State that have the drug in stock at a price below the maximum allowable cost at the time the pharmacy or pharmacist purchased the drug.
(2) At the time the pharmacy benefits manager provides the written notice of a final appeal determination under paragraph (c)(1) of this section, the pharmacy benefits manager shall provide notice to the pharmacy of the right to appeal an adverse determination to the Department.
(3) The notice under paragraph (c)(2) of this section may be separate from or a part of the written notice of the final determination under paragraph (c)(1) of this section and must, at a minimum, contain all of the following:
a. A statement that says “You have the right to appeal the final appeal determination through the Delaware Department of Insurance. All appeals must be filed with the Department within 10 calendar days from the date you receive the pharmacy benefits manager’s final determination.”
b. The Department website the pharmacy can use to file an appeal.
(d) If the appeal is granted the pharmacy benefits manger shall do the following:
(1) a. Adjust the reimbursement for the drug as of the date of the original claim for payment.
b. Without requiring the appealing pharmacy to reverse and rebill the claims, provide reimbursement for the claim and any subsequent and similar claims under similarly applicable contracts with the pharmacy benefits manager as follows:
1. For the original claim, in the first remittance to the pharmacy after the date the appeal was granted.
2. For subsequent and similar claims under similarly applicable contracts, in the second remittance to the pharmacy after the date the appeal was granted.
(2) For a similarly situated contracted pharmacy in this State, do all of the following:
a. Adjust the maximum allowable cost for the drug as of the date the appeal was granted.
b. Provide notice to the pharmacy or the pharmacy’s contracted agent of all of the following:
1. That an appeal was granted.
2. That without filing a separate appeal, the pharmacy or the pharmacy’s contracted agent may reverse and rebill a similar claim.
(e) A pharmacy benefits manager shall provide information on its website about the appeal process, including all of the following:
(1) A telephone number at which the contracted pharmacy may contact the department or office responsible for processing appeals for the pharmacy benefits manager to speak to an individual specifically or leave a message for an individual or office who is responsible for processing appeals.
(2) An email address of the department or office responsible for processing appeals to which an individual who responsible for processing appeals has access.
(3) The information required under paragraph (c)(3) of this section.
(f) A pharmacy benefits manager may not charge a contracted pharmacy a fee related to the re-adjudication of a claim resulting from a granted appeal under subsection (d) of this section or the granting of an appeal under subsection (h) of this section.
(g) A pharmacy benefits manager may not retaliate against a contracted pharmacy for exercising its right to appeal to the pharmacy benefits manager under subsection (a) of this section or to the Commissioner under subsection (h) of this section.
(h) (1) If a pharmacy benefits manager denies an appeal and a contracted pharmacy files an appeal with the Commissioner, the Commissioner shall do all of the following:
a. Review the pharmacy benefits manager’s compensation program to ensure that the reimbursement for pharmacy benefits management services paid to the pharmacist or a pharmacy complies with the reimbursement requirements under § 3372A(7) of this title.
b. Based on a determination made by the Commissioner under paragraph (h)(1)a. of this section, do 1 of the following:
1. Deny the appeal.
2. Grant the appeal and order the pharmacy benefits manager to pay the claim in accordance with the Commissioner’s findings.
(2) All pricing information and data collected by the Commissioner during a review required by paragraph (h)(1) of this section is confidential and not subject to subpoena or the Freedom of Information Act, Chapter 100 of Title 29.
(3) The non-prevailing party shall pay the costs incurred by the Department in processing an appeal under this subsection.
(4) On request, parties shall provide the Commissioner all mathematical calculations, accounts, records, documents, files, logs, correspondence, or other information necessary to complete the Commissioner’s review of an appeal under this subsection.
Source: DE Code (Official Site)URL: https://delcode.delaware.gov/title18/c033a/sc02/index.htmlFetched: 10/4/2026