Code of Maryland Regulations (Last Updated: April 6, 2021) |
Title 31. Maryland Insurance Administration |
Subtitle 10. HEALTH INSURANCE—GENERAL |
Chapter 31.10.47. Cost Pricing and Reimbursement Other than MAC |
Sec. 31.10.47.03. Disclosures to a Contracted Pharmacy
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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. Except as provided in §§C and D 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.
C. 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.
D. The disclosure described in §C shall be:
(1) Provided during claims processing; or
(2) Described in detail on the initial remittance advice.
E. 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.