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 15-1633 – When Request Allowed
A pharmacy benefits manager or its agent may not request a therapeutic interchange unless: (1) the proposed therapeutic interchange is for medical reasons that benefit the beneficiary; or (2) the proposed therapeutic interchange will result in financial savings and benefits to the purchaser or the beneficiary.
Section 15-1634 – Authorization; Disclosures; Money-Saving Claims; Payment for Interchange
(a) Before making a therapeutic interchange, a pharmacy benefits manager or its agent shall obtain authorization from a prescriber or an individual authorized by the prescriber. (b) In any therapeutic interchange solicitation, the following shall be disclosed to the prescriber: (1) that a therapeutic interchange is being solicited; (2) the circumstances under which the originally prescribed drug will be […]
Section 15-1635 – Requirements When Interchange Occurs
If a therapeutic interchange occurs, the pharmacy benefits manager or its agent shall: (1) disclose to the beneficiary, orally or in writing: (i) that the pharmacy benefits manager or its agent requested a therapeutic interchange by contacting the beneficiary’s prescriber; (ii) the prescriber approved the therapeutic interchange; (iii) the names of the originally prescribed drug and the drug dispensed […]
Section 15-1617 – Required Policies, Procedures, and Processes
A pharmacy benefits manager shall ensure that its pharmacy and therapeutics committee has: (1) policies and procedures, including disclosure requirements, to address potential conflicts of interest that members of the pharmacy and therapeutics committee may have with developers or manufacturers of prescription drugs; (2) a process to evaluate medical and scientific evidence concerning the safety and effectiveness […]
Section 15-1636 – Cancellation and Reversal
(a) A pharmacy benefits manager or its agent shall cancel and reverse a therapeutic interchange on written or verbal instructions from a prescriber, the beneficiary, or the beneficiary’s representative. (b) If a therapeutic interchange is reversed, the pharmacy benefits manager or its agent shall: (1) obtain a prescription for and dispense the originally prescribed prescription drug; and (2) charge […]
Section 15-1618 – Accreditation
The Commissioner may consider a pharmacy and therapeutics committee of a pharmacy benefits manager as having met the requirements of §§ 15–1614 and 15–1617 of this part if the pharmacy benefits manager has obtained accreditation from an accrediting organization approved by the Commissioner.
Section 15-1637 – Maintenance of Toll-Free Telephone Number
(a) A pharmacy benefits manager shall maintain a toll–free telephone number Monday through Saturday for prescribers, pharmacies, pharmacists, and beneficiaries to request information regarding a therapeutic interchange. (b) The toll–free telephone number shall be accessible from 8 a.m. until at least 8 p.m. Eastern Standard Time.
Section 15-1619 – Regulations
The Commissioner may adopt regulations to implement this part.
Section 15-1638 – Privacy Standards
All disclosures made under this part shall comply with the privacy standards set forth in State and federal law.