Code of Maryland Regulations
Title 31 - MARYLAND INSURANCE ADMINISTRATION
Subtitle 10 - HEALTH INSURANCE-GENERAL
Chapter 31.10.47 - Cost Pricing and Reimbursement Other than MAC
Section 31.10.47.02 - Definitions
Universal Citation: MD Code Reg 31.10.47.02
Current through Register Vol. 51, No. 19, September 20, 2024
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) "Appeal decision " means a written or electronic notice in response to an appeal under this chapter provided to a contracted pharmacy that includes a reason for the appeal denial.
(2) "Beneficiary" means an individual who receives prescription drug coverage or benefits from a purchaser.
(3) "Carrier" means:
(a) An insurer;
(b) A nonprofit health service plan; or
(c) A health maintenance organization.
(3) "Carrier" has the meaning stated in Insurance Article, §
15-1601, Annotated Code of Maryland.
(4) "Compensation program" has the meaning stated in Insurance Article, §
15-1601, Annotated Code of Maryland.
(5) "Complaint" means a communication by a contracted pharmacy that disputes the appeal decision, and is submitted on a complaint form to the Commissioner, after the pharmacy benefits manager's internal appeal process has been exhausted as required by Insurance Article, §
15-1628.2, Annotated Code of Maryland.
(6) "Complaint form" means the form developed by the Commissioner under Regulation .05 of this chapter.
(7) "Contracted pharmacy" has the meaning stated in Insurance Article, §
15-1601, Annotated Code of Maryland.
(8) "Direct or indirect remuneration fee " means an adjustment in total compensation received directly or indirectly by a contracted pharmacy from a PBM that is determined after the sale of the product or service, including an adjustment of an adjudicated claim based on the use of a generic effective rate or fee or performance-based reimbursement.
(9) "Participating pharmacy contract" means a contract filed with the Commissioner that is:
(a) Between a pharmacy and a:
(i) Pharmacy benefits manager;
(ii) Pharmacy services administrative organization; or
(iii) Group purchasing organization;
(b) Filed as required by the Commissioner;
(c) Not disapproved by the Commissioner; and
(d) In compliance with the requirements stated in this chapter.
(10) "Pharmacist" has the meaning stated in Health Occupations Article, §
12-101, Annotated Code of Maryland.
(11) "Pharmacy" has the meaning stated in Health Occupations Article, §
12-101, Annotated Code of Maryland.
(12) "Pharmacy benefits management services" has the meaning stated in Insurance Article, §
15-1601, Annotated Code of Maryland.
(13) "Pharmacy benefits manager" or "PBM" has the meaning stated in Insurance Article, §
15-1601, Annotated Code of Maryland.
(14) "Pharmacy services administration organization" or "PSAO" means an entity that provides a contracted pharmacy with contracting administrative services relating to prescription drug benefits.
(15) "Pricing information" means anything used in the mathematical calculation to determine the payment to a contracted pharmacy.
(16) "Purchaser" has the meaning stated in Insurance Article, §
15-1601, Annotated Code of Maryland.
(17) Review Decision.
(a) "Review decision " means a written or electronic notice in response to a request from a contracted pharmacy for a review of a failure to pay the contractual reimbursement amount of a submitted claim.
(b) "Review decision " does not include an appeal decision.
(18) "Source " means the publisher or publishers stated in the participating pharmacy contract, used by the PBM, in any manner, to establish the basis of the PBM's pricing or the reimbursement amount to a contracted pharmacy, under a participating pharmacy contract's stated compensation program.
(19) "Working day" means any day that the Maryland Insurance Administration is open for business.
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