Code of Maryland Regulations
Title 31 - MARYLAND INSURANCE ADMINISTRATION
Subtitle 10 - HEALTH INSURANCE-GENERAL
Chapter 31.10.48 - Pharmacy Benefits Managers-Informational Filing of Contracts and Amendments
Section 31.10.48.04 - Noncompliant Contract Terms

Universal Citation: MD Code Reg 31.10.48.04

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

A. A PBM may have a contract form or amendment to a contract form disapproved at any time after the contract form or amendment to a contract form has been submitted as part of an informational filing if the contract form or amendment form contains or uses any language that:

(1) Violates Insurance Article, Title 15, Subtitle 16, Annotated Code of Maryland, or any applicable statutory provisions, including but not limited to Insurance Article, §§ 15-112, 15-112.2(a) -(e), 15-123(d), 15-1004, 15-1005, 15-1008(c), 15-1009, 15-1628-15-1628.3, 15-1629, 15-1631, and 15-1633-15-1639, and Health-General Article, §§ 19-710(s) and (t) and 19-712.2, Annotated Code of Maryland;

(2) Does not disclose the components of the compensation program through which a reimbursement rate is set;

(3) Includes a definition of "multisource generic drug " that is inconsistent with COMAR 31.10.46, or "generic" or "brand name drug" that is inconsistent with Health Occupations Article, § 12-504, Annotated Code of Maryland;

(4) Allows the PBM to reimburse a covered drug in an amount that differs, including zero, based on the identity of the wholesale distributor used by a contracting pharmacy for acquisition of the covered drug;

(5) Except for instances of error or fraud, allows the PBM to reclassify, recategorize, or recharacterize an adjudicated claim;

(6) In any way prohibits or restricts a pharmacist or pharmacy from filing a complaint with the Commissioner; or

(7) Fails to include the internal appeal provisions in the contract.

B. No provisions in Insurance Article, Annotated Code of Maryland, or this chapter may be waived or modified by contract.

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