Code of Maryland Regulations
Title 31 - MARYLAND INSURANCE ADMINISTRATION
Subtitle 10 - HEALTH INSURANCE-GENERAL
Chapter 31.10.46 - Pharmacy Benefits Managers-Maximum Allowable Cost
Section 31.10.46.03 - Disclosures to a Contracted Pharmacy

Universal Citation: MD Code Reg 31.10.46.03

Current through Register Vol. 51, No. 19, September 20, 2024

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. 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.

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