Sec. 31.10.47.03. Disclosures to a Contracted Pharmacy  


Latest version.
  • 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.