Section 15-2008 – Adoption of Regulations
The Commissioner may adopt regulations to implement this subtitle.
Section 15-1642 – Violations; Enforcement
(a) It is a violation of this subtitle for a pharmacy benefits manager to: (1) misrepresent pertinent facts or policy provisions that relate to a claim or the compensation program at issue in a complaint or an appeal of a decision regarding a complaint; (2) refuse to pay a claim for an arbitrary or capricious reason based on […]
Section 15-2009 – Review Authority Not Diminished
This subtitle may not be construed to diminish the authority of the Office of the Attorney General or the Commissioner to obtain information relating to a pharmacy services administrative organization and use the information in any proceeding.
Section 15-1701 – Definitions
(a) In this subtitle the following words have the meanings indicated. (b) “Carrier” has the meaning stated in § 15–1301 of this title. (c) “Enrollee” means an individual entitled to health care benefits from a carrier. (d) “Physician rating system” means any program that: (1) measures, rates, or tiers the performance of physicians under contract with the carrier; and (2) discloses […]
Section 15-2010 – Filing of Contract or Amendment to Contract
(a) A pharmacy services administrative contract or an amendment to a pharmacy services administrative contract or a contract or an amendment to a contract between a pharmacy services administrative organization, on behalf of an independent pharmacy, and a pharmacy benefits manager or group purchasing organization may not become effective unless: (1) at least 60 days before the […]
Section 15-1702 – General Consideration
(a) A carrier may not use a physician rating system unless the physician rating system is approved by a ratings examiner. (b) A carrier shall contract with and pay for a ratings examiner to review any physician rating system of the carrier. (c) A physician rating system of a carrier is deemed to meet the requirements of this […]
Section 15-2011 – Provision of Certain Documents by Pharmacy Services Administrative Organization — Confidential
(a) A pharmacy services administrative contract shall include a provision that requires the pharmacy services administrative organization to provide to the independent pharmacy a copy of any contracts, amendments, payment schedules, or reimbursement rates within 5 working days after the execution of a contract, or an amendment to a contract, signed on behalf of the independent […]
Section 15-1628 – Required Disclosures by Pharmacy Benefits Manager; Filing Requirements for Contract or Amendment to Contract
(a) For disputes regarding cost pricing and reimbursement under a participating pharmacy contract, each participating pharmacy contract must include a process to appeal, investigate, and resolve disputes regarding cost pricing and reimbursement that includes: (1) a requirement that an appeal be filed by the contract pharmacy not later than 21 days after: (i) the date a direct or […]
Section 15-1628.1 – Maximum Allowable Cost Pricing Between Pharmacy Benefits Manager and Contracted Pharmacy
(a) (1) In this section the following words have the meanings indicated. (2) “Drug shortage list” means a list of drug products listed on the federal Food and Drug Administration’s Drug Shortages website. (3) (i) “Maximum allowable cost” means the maximum amount that a pharmacy benefits manager or a purchaser will reimburse a contracted pharmacy for the cost of a […]
Section 15-1628.3 – Fee or Performance-Based Reimbursement Related to Claim Adjudication
(a) A pharmacy benefits manager or a carrier may not directly or indirectly charge a contracted pharmacy, or hold a contracted pharmacy responsible for, a fee or performance–based reimbursement related to the adjudication of a claim or an incentive program. (b) A pharmacy benefits manager or carrier may not make or allow any reduction in payment for […]