Sec. 31.10.46.03. Disclosures to a Contracted Pharmacy

A. A PBM, whether its contract is directly with a pharmacy or indirectly with a pharmacy through a PSAO or group purchasing organization, shall disclose to a contracted pharmacy at the time of entering into a contract with a pharmacy and at least 30 working days before any contract change for a contracted pharmacy:

(1) The applicable terms, conditions, and reimbursement rates, including:

(a) The sources; and

(b) The terms of the compensation program;

(2) The process and procedures for verifying pharmacy benefits and beneficiary eligibility;

(3) The dispute resolution, internal appeal process under Regulation .04 of this chapter, and audit appeals process; and

(4) The process and procedures for verifying the prescription drugs included on the formularies used by the PBM.

B. A PBM, whether its contract is directly with a pharmacy or indirectly with a pharmacy through a PSAO or group purchasing organization, shall:

(1) Update its pricing information at least every 7 days;

(2) Establish a reasonable process by which a contracted pharmacy has access to the current and applicable MAC lists and price list in an electronic format as updated in accordance with the requirements of this section; and

(3) Immediately after a pricing information update occurs pursuant to this regulation, use the updated pricing information in calculating the payments made to all contracted pharmacies.

C. Except as provided in §§D and E of this regulation, a contracted pharmacy may not be charged a fee or held responsible by a purchaser or PBM for:

(1) A fee or performance-based reimbursement related to an adjudicated claim; or

(2) An incentive program.

D. A PBM, whether its contract is directly with a pharmacy or indirectly with a pharmacy through a PSAO or group purchasing organization, shall disclose any fee or performance-based reimbursement that relates to the adjudication of a claim or incentive program by stating:

(1) The specific dollar amount of a fee or alternative reimbursement; or

(2) The specific percentage of the potential adjustment relating to reimbursement of a claim.

E. The disclosure described in §D shall be:

(1) Provided during claims processing; or

(2) Described in detail on the initial remittance advice.

F. A claim paid on behalf of a carrier to a contracted pharmacy under a participating pharmacy contract is subject to the requirements of Insurance Article, §§15-1005, 15-1008, 15-1009, and 15-1631, Annotated Code of Maryland.